Documents

CMN

Custom Orthotics

• Elbow Support
• Lumbar Orthosis
• Ankle Orthosis

Mobility

• Mobility Assistive Equipment — Face to Face Examination Report
• CMN for Manual Wheelchair
• CMN for Transcutaneous Electrical Nerve Stimulator (TENS)
• Seat Life Mechanisms
• Osteogenesis Stimulators
• Certifying Physician Therapeutic Shoes

Wound Care

• Negative Pressure Wound Therapy Pump
• Amendment Plan of Care for Decubi’s Ulcers
• Statement of Ordering Physician Group 1 Support Surfaces
• Statement of Ordering Physician Group 2 Support Surfaces
• Custom Compression Garment Measurement Form

Enteral

• Enteral and Parenteral Nutrition

Respiratory

• CMN for Oxygen
• CMN for Pneumatic Compression Device
• Lymphedima Pump Physician Form (E0651)
• Lymphedima Pump Physician Form (E0652)

Home Care

• CMN for Hospital Bed

Sample Letters

• Letter of Medical Necessity – Foot Orthotics
• Letter of Medical Necessity – Foot Orthotics 2
• Letter of Medical Necessity – AFO
• Patient Agreement of Payment