Fillable form certificate necessity

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB No. 0938-0679 CERTIFICATE OF MEDICAL NECESSITY CMS-854 CONTINUATION FORM PATIENT NAME SECTION C DME 11. PHYSICIAN Attestation and Signature/Date I certify that I am the treating physician identified in Section A of this form. I have received Sections A B and C of the Certificate of Medical Necessity including charges for items ordered. PHYSICIAN S SIGNATURE DATE // Form CMS-854 09/05 EF 08/2006 INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY SECTION C CONTINUATION FORM CMS-854 To be completed by the supplier NARRATIVE DESCRIPTION OF EQUIPMENT COST Provide 1 a narrative description of the item s ordered as well as all options...
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