CERTIFICATE OF MEDICAL NECESSITYCMS-854 321 CONTINUATION FORMDEPARTMENTOF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES PATIENTNAME Icertify that I am the treating physician identified in Section Aof this form. I have received Sections A, B and C of the Certificate of MedicalNecessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certifythat 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 section may subject me to civil or criminal liability.PHYSICIAN325S SIGNATURE DATE // SECTION DPHYSICIAN Attestation and Signature/Date DME 11.0 (1)Narrative description of all items, accessories and options ordered; (2) Supplier's charge; and (3) Medicare Fee Schedule Allowance for eachitem, accessory and option. (see instructions on back.) SECTION CNarrative Description of Equipment and Cost (continued) Form CMS-854 (/) American LegalNet, Inc. www.FormsWorkFlow.com SECTION C:(To be completed by the supplier)NARRATIVEProvide (1) a narrative description of the item(s) ordered, as well as all options, accessories; (2) the product, model and DESCRIPTION OF serial number of the product being delivered (if applicable); (3) the supplier325s charge for each item, option, accessory; and EQUIPMENT&COST:(4)the Medicare fee schedule allowance for each item/option/accessory/supply/drug, if applicable.SECTION D:(To be completed by the physician)PHYSICIANThe physician's signature certifies(1) the CMN which he/she is reviewing includes Sections A, B, C and D;: (2) the answers ATTESTATION:in Section B are correct; and (3) the self-identifying information in Section Ais correct. PHYSICIAN SIGNATUREAfter completion and/or review by the physician of Sections A, B and C, the physician must sign and date the CMN in ANDDATE: Section D, verifying the Attestation appearing in this Section. The physician's signature also certifies the items ordered are medically necessary for this patient INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITYSECTION C CONTINUATION FORM (CMS-854) 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 forthis information collection is 0938-0679. The time required to complete this information collection is estimated to average 12 minutes per response, including the time to review instructions, searchexisting resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improvingthis form, please write to: CMS, Attn: PRAReports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/for information on claim filing. Form CMS-854 (0/) American LegalNet, Inc. www.FormsWorkFlow.com