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Jan 1, 2006 · The following provides access and/or information for many CMS forms. You may also use the "Search" feature to more quickly locate information for a specific form number or form title.

This section is used to gather clinical information to determine medical necessity. Answer each question which applies to the items ordered, checking “Y” for yes, “N” for no, or ill in the blank if other information is requested.

This section is used to gather clinical information to help Medicare determine the medical necessityfor the item(s) being ordered. Answer each question which applies to the items ordered, checking “Y” for yes, “N” for no, or “D” for does notapply.

QUESTION SECTION: This section is used to gather clinical information to determine medical necessity. Answer each question which applies to the items ordered, circling "Y" for yes, "N" for no, "D" for does not apply, a number if this is offered as an answer option,

QUESTION SECTION: This section is used to gather clinical information to determine medical necessity. Answer each question which applies to the items ordered, circling "Y" for yes, "N" for no, "D" for does not apply, a number if this is offered as an answer option,

This section is used to gather clinical information to help Medicare determine the medical necessity for the item(s) being ordered. Answer each question which applies to the items ordered, checking “Y” for yes, “N” for no, or “D” for

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).

The medical necessity requirements for Medicare coverage of ambulance services are set forth in 42 CFR §410.40(d). Medicare covers ambulance services including air ambulance (fixed wing and rotary wing), when: • Furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated. 1

This section is used to gather clinical information to help Medicare determine the medical necessity for the item(s) being ordered. Answer each question which applies to the items ordered, checking “Y” for yes, “N” for no, or “D” for

codes that would further describe the medical need for the item (up to 3 codes). QUESTION SECTION: This section is used to gather clinical information to determine medical necessity. Answer each question which applies to