Activeforever Pride Lift Chair LC310 User Manual

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0679

CERTIFICATE OF MEDICAL NECESSITY DMERC 07.02A

SEAT LIFT MECHANISM

SECTION A Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER

ActiveForever 10799 N. 90th St. Scottsdale, AZ 85260

(__

__ __) __ __ __ - __ __ __ __ HICN

PLACE OF SERVICE

NAME and ADDRESS of FACILITY if applicable (See

Reverse)

HCPCS CODE:

E062__nu

(__ __ __) __ __ __ - __ __ __ __ NSC #

480 767-6800 N/A

PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.)

PHYSICIAN NAME, ADDRESS (Printed or Typed)

PHYSICIAN'S UPIN:

PHYSICIAN'S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __

SECTION B Information in this Section May Not Be Completed by the Supplier of the Items/Supplies.

EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME) DIAGNOSIS CODES (ICD-9):

ANSWERS ANSWER QUESTIONS 1 -5 FOR SEAT LIFT MECHANISM

e Y for Yes, N for No, or D for Does Not Apply)

(Circl

Y N D 1. Does the patient have severe arthritis of the hip or knee?

Y N D 2. Does the patient have a severe neuromuscular disease?

Y N D 3. Is the patient completely incapable of standing up from a regular armchair or any chair in his/her home?

Y N D 4. Once standing, does the patient have the ability to ambulate?

Y N D

NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):

: TITLE: EMPLOYER:

NAME

5. Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position (e

.g., medication, physical therapy) been tried and failed? If YES, this is documented in the patient's medical records.

SECTION C Narrative Description Of Equipment And Cost

(1) Narrative description of all items, accessories and options ordered; (2) Supplier's charge; and (3) Medicare Fee Schedule

Allowance for each item, accessory, and option. (See Instructions On Back)

SECTION D Physician Attestation and Signature/Date

I certify that I am the 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). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in Section B is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that sec

tion may subject me to civil or criminal liability.

PHYSICIAN'S SIGNATURE DATE / / (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTABLE)

CMS 849 (04/96)

SECTION A: (May be completed by the supplier)

www.ActiveForever.com

CERTIFICATION TYPE/DATE

this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the space marked NITIAL." If this is a revised certification (to be completed when the physician changes the order, based on the patient's

"I changing

clinical needs), indicate the initial date needed in the space marked "INITIAL," and also indicate the recertification

date in the space marked "REVISED." If this is a recertification, indicate the initial date needed in the space marked

NITIAL," and also indicate the recertification date in the space marked "RECERTIFICATION." Whether submitting a

"I REVISED or a RECERTIFIED CMN, be sure to always furnish the INITIAL date as well as the REVISED or RECERTIFICATION date.

PATIEN INFORMATION

SUPPL INFORMATION

PLACE

IER

OF SERVICE: Indicate the place in which the item is being used, i.e., patient's home is 12, skilled nursing facility (SNF) is 31, End Stage

Indicate

the patient's name, permanent legal address, telephone number and his/her health insurance claim number (HICN)

it appears on his/her Medicare card and on the claim form.

Indicate

the name of your company (supplier name), address and telephone number along with the Medicare Supplier assigned to you by the National Supplier Clearinghouse (NSC).

Number

Renal

Disease (ESRD) facility is 65, etc. Refer to the DMERC supplier manual for a complete list.

FACILITY NAME: If the place of service is a facility, indicate the name and complete address of the facility.

CODES: List all HCPCS procedure codes for items ordered that require a CMN. Procedure codes that do not require certification

HCPCS

PATIENT WEIGHT

PHYSICIAN ADDRESS

DOB, HEIGHT,

AND SEX:

NAME,

UPIN: Accurately

PHYSICIAN' TELEPHONE

CTION B: (May not be completed by the supplier. While this section may be completed by a non-physician clinician, or a

EST.

NO:

LENGTH OF NEED: Indicate the estimated length of need (the length of time the physician expects the patient to require use of the ordered item)

not be listed on the CMN.

should

Indicate

patient's date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in pounds, if requested.

icate the physician's name and complete mailing address.

Ind

indicate the ordering physician's Unique Physician Identification Number (UPIN).

Indicate

the telephone number where the physician can be contacted (preferably where records would be accessible

taining to this patient) if more information is needed.

per

physician

by his/her

employee, it must be reviewed, and the CMN signed (in Section D) by the ordering physician.)

filling in the appropriate number of months. If the physician expects that the patient will require the item for the duration of

life, then enter 99.

DIAGNOSIS

QUESTION

NAME ANSWERING QUESTIONS

CODES: In the first space, list the ICD9 code that represents the primary reason for ordering this item. List any additional ICD9 codes

that

would further describe the medical need for the item (up to 3 codes).

SECTION: This section is used to gather clinical information to determine medical necessity. Answer each question which applies to

items ordered, circling "Y" for yes, "N" for no, "D" for does not apply, a number if this is offered as an answer option, or

OF PERSON

the fill in the blank if other information is requested

a clinical professional other than the ordering physician (e.g., home health nurse, physical therapist, dietician),

SECTION B or a physician employee answers the questions of Section B, he/she must print his/her name, give his/her professional title

the name of his/her employer where indicated. If the physician is answering the questions, this space may be left blank.

and

SECTION C: (To be completed by the supplier)

NARRATIV DESCR EQUIPMENT

PHYSICIA ATTESTATION

PHYSICIAN AND

IPTION OF

& COST:

CTION D: (To be completed by the physician)

SIGNATURE

DATE:

Supplier gives (1) a narrative description of the item(s) ordered, as well as all options, accessories, supplies and drugs;

) the supplier's charge for each item, option, accessory, supply and drug; and (3) the Medicare fee schedule allowance for

item/option/accessory/supply/drug, if applicable.

each

The

physician's signature certifies (1) the CMN which he/she is reviewing includes Sections A, B, C and D; (2) the answers

in Section B are correct; and (3) the self-identifying information in Section A is correct.

After completion and/or review by the physician of Sections A, B and C, the physician must sign and date the CMN in Section D, verifying the Attestation appearing in this Section. The physician's signature also certifies the items ordered are

medically necessary for this patient. Signature and date stamps are not acceptable.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this

formation collection is 0938-0679. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing

in resources

, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please

write

to: CMS, 7500 Security Blvd., N2-14-26, Baltimore, Maryland 21244-1850.