Transcription of HEALTH CARE FINANCING ADMINISTRATION …
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HEALTH CARE FINANCING ADMINISTRATION …
DEPARTMENT OF HEALTH & HUMAN SERVICESFORM APPROVEDHEALTH care FINANCING ADMINISTRATIONOMB NO. 0938-0679 certificate OF medical NECESSITYDMERC WHEELCHAIRSSECTION ACertification Type/Date: INITIAL ___/___/___ REVISED ___/___/___PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER(__ __ __) __ __ __ - __ __ __ __ HICN _____SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER(__ __ __) __ __ __ - __ __ __ __ NSC # _____ PLACE OF SERVICE _____ HCPCS CODEPT DOB ____/____/____; Sex ____ (M/F) ; (in.) ; (lbs.)NAME and ADDRESS of FACILITY if applicable (SeeReverse) PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN NUMBER(__ __ __) __ __ __ - __ __ __ __ UPIN # _____SECTION BInformation in This Section May Not Be Completed by the Supplier of the LENGTH OF NEED (# OF MONTHS): _____ 1-99 (99=LIFETIME)DIAGNOSIS CODES (ICD-9): _____ _____ _____ _____ITEM ADDRESSEDANSWERSANSWER QUESTIONS 1, 5, 8 AND 9 FOR MANUAL WHEELCHAIR BASE, 1-5 FOR WHEELCHAIROPTIONS/ACCESSORIES.
u.s. department of health & human services form approved health care financing administration omb no. 0938-0679 certificate of medical necessity dmerc 02.03b
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