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Certificate of Medical Necessity Forms

Certificate of Medical Necessity Forms

The following forms are the most commonly used forms to request durable medical and respiratory equipment and supplies. If you do not see the form you are looking for or have any questions, please contact provider services at: 1-888-865-5290.

Funds’ Medical Justification Form for:

Durable Medical and Respiratory Equipment

CMS Forms and Instructions:

CMS 484 – Oxygen

CMS 846 – Pneumatic Compression Devices

CMS 847 – Osteogenesis Stimulators

CMS 848 – TENs Stimulator

CMS 849 – Seat Lift Mechanisms

CMS 10125 – External Infusion Pumps

CMS 10126 – Enteral and Parenteral Nutrition

CMS 854 – Continuation Form (for any of the above CMS forms)

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