COURT U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES COUNTY . . CENTERS FOR MEDICARE. & MEDICAID . . . . . . . . . . . . . . . . . . .OF. . . . . . . . . SERVICES FORM APPROVED OMB NO. 0938-0679 ....................... CERTIFICATE OF MEDICAL :NECESSITY Index No. DMERC 10.02B ENTERAL NUTRITION SECTION A Certification Type/Date: PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER INITIAL ___/___/___ : REVISED ___/___/___No. Calendar RECERTIFICATION ___/___/___ SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER : JUDICIAL SUBPOENA Plaintiff(s) -against- : (__ __ __) __ __ __ - __ __ __ __ HICN (__ __ __) __ __ __ - __ __ __ __ NSC # : PLACE OF SERVICE ________ PT DOB ____/____/____; Sex ____ (M/F) ; HCPCS CODES: HT.______(in.) ; WT._______(lbs.) : NAME and ADDRESS of FACILITY if applicable (See PHYSICIAN NAME, ADDRESS (Printed or Typed) Reverse) Defendant(s) : ...................................................... PHYSICIAN'S UPIN: PHYSICIAN'S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __ SECTION B Information OF NEW YORK THE PEOPLE OF THE STATEin this Section May Not Be Completed by the Supplier of the Items/Supplies. EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME) TO ANSWERS DIAGNOSIS CODES (ICD-9): ANSWER QUESTIONS 7, 8, AND 10 - 15 FOR ENTERAL NUTRITION (Circle Y for Yes, N for No, or D for Does Not Apply, Unless Otherwise Noted) Questions 1 - 6, and 9, reserved for other or future use. GREETINGS: Y N 7. Does the patient have permanent non-function or disease of the structures that normally permit food to reach or be absorbed from the small bowel? Y WE COMMAND YOU, thatpatient require tube feedings to provide laid aside, you to maintain weight and strength N 8. Does the all business and excuses being sufficient nutrients and each of you attend before commensurate with the patient's overall health status? , the Honorable at the Court located at County of A) 10. Print product name(s). in room , on the day of , 20 , at o'clock in the noon, and at any recessed B) or adjourned date, to testify and give evidence as a witness in this action on the part of the A) 11. Calories per day for each product? B) Your failure to comply with week subpoena is punishable as a contempt of court and will make you liable to 12. Days per this administered? (Enter 1 - 7) the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. the number for method of administration? 13. Circle 1 2 3 4 1 - Syringe 2 - Gravity 3 - Pump 4 - Does not apply Witness, Honorable , one of the Justices of the 14. Court Y N D in County, Does the patient have a documented allergy or intolerance to semi-synthetic nutrients? day of , 20 15. Additional information when required by policy: (Attorney must sign above NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print): and type name below) NAME: TITLE: EMPLOYER: SECTION C Narrative Description Of Equipment And Cost (1) Narrative description of all items, accessories and options ordered; Attorney(s) for (2) Supplier's charge; and (3) Medicare Fee Schedule Allowance for each item, accessory, and option. (See Instructions On Back) Office and P.O. Address SECTION D Physician Attestation and Signature/Date Telephone No.: 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 Facsimile No.: 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 E-Mail Address: section may subject me to civil or criminal liability. PHYSICIAN'S SIGNATURE DATE / Mobile Tel. No.: / (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTABLE) CMS-853 (04/96) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. SECTION A: (May be completed by the supplier) : CERTIFICATION TYPE/DATE: Index No. If this is an initial certification for this patient, indicate this by placing date (MM/DD/YY) needed initially in the space marked "INITIAL." If this is a revised certification (to be completed when the physician changes the order, based on the : Calendar No. patient's 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 “INITIAL,” and also indicate the recertification: date in the space marked "RECERTIFICATION." Whether Plaintiff(s) submitting a REVISED or a RECERTIFIED CMN, be sure to always furnish the INITIAL date as well as the REVISED or RECERTIFICATION date. -against- JUDICIAL SUBPOENA : PATIENT INFORMATION: Indicate the patient's name, permanent legal address, telephone number and his/her health insurance claim number (HICN) as it appears on his/her Medicare card and on the claim form. : SUPPLIER INFORMATION: Indicate the name of your company (supplier name), address and telephone number along with the Medicare Supplier : Number assigned to you by the National Supplier Clearinghouse (NSC). Indicate the place in which the item is being used; i.e., patient's home is 12, skilled nursing facility (SNF) is 31, End Defendant(s) : . . . . . . . . . . . . . . . Stage . . . . .Disease (ESRD) .facility. is .65,. etc..Refer .to the .DMERC supplier manual for a complete list. . . . . Renal . . . . . . . . . . . . . . . . . . . . . . . PLACE OF SERVICE: FACILITY NAME: If the place of service is a facility, indicate the name and complete address of the facility. HCPCS CODES: List all HCPCS procedure codes for items ordered that require a CMN. Procedure codes that do not require certification THE PEOPLE OFshould not be listed onNEW YORK THE STATE OF the CMN. PATIENT DOB, HEIGHT, TO WEIGHT AND SEX: Indicate patient's date of birth (MM/DD/YY) and sex (male or female); height in inches and weight in pounds, if requested. PHYSICIAN NAME, ADDRESS: Indicate the physician's name and complete mailing address. UPIN: GREETINGS: Accurately indicate the ordering physician's Unique Physician Identification Number (UPIN). PHYSICIAN'S TELEPHONE NO: Indicate the telephone number where the physician can be contacted (preferably where records would be accessible EST. 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) by filling in the appropriate number of months. If the physician expects that the patient will require the item for the duration of his/her life, then enter 99. WE COMMANDto this patient) if more information isexcuses being laid aside, you and each of you attend before pertaining YOU, that all business and needed. , the Honorable at the Court located at County of SECTION B: (May not be completed by the supplier. While this section may be completed by a non-physician clinician, in room , a the day of , 20 , at o'clock Section noon, and at any recessed oronphysician employee, it must be reviewed, and the CMN signed (inin the D) by the ordering physician.) or adjourned date, to testify and give evidence as a witness in this action on the part of the DIAGNOSIS CODES: Your In the first space, with ICD9 code that is punishable as a contempt of court item. List make you ICD9 failure to comply list thethis subpoenarepresents the primary reason for ordering this and willany additionalliable to codes that this subpoena was the medical need for the item penalty of $50 and all damages sustained as a the party on whose behalf would further describe issued for a maximum (up to 3 codes). result of your QUESTION SECTION: failure to comply. 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, or fill in the blank if other information is requested. Witness, Honorable , one of the Justices of the If a clinical professional other than the ordering physician (e.g., home health nurse, physical therapist, dietician), or a County, day of , 20 NAME OF PERSON Court in ANSWERING SECTION B QUESTIONS: physician employee answers the questions of Section B, he/she must print his/her name, give his/her professional title and the name of his/her employer where indicated. If the physician is answering the questions, this space may be left blank. SECTION C: (To be completed by the supplier) NARRATIVE DESCRIPTION OF EQUIPMENT & COST: Supplier gives (1) a narrative description of the item(s) ordered, as well as all options, accessories,supplies and drugs; (2) the supplier's charge for each item, option, accessory, supply and drug; and (3) the Medicare fee schedule allowance for each item/option/accessory/supply/drug, if applicable. SECTION D: (To be completed by the physician) PHYSICIAN ATTESTATION: 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. Office and P.O. Address PHYSICIAN SIGNATURE 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. (Attorney must sign above and type name below) Attorney(s) for Telephone No.: Facsimile No.: 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 information collection is 0938-0679. The time required to complete this information collection is estimated to average 15 minutes per response, E-Mail Address: including the time to review instructions, search existing resources, gather the data needed, and complete and review the information collection. If you have any comments Mobile Tel. Blvd., concerning the accuracy of the time estimate(s), or suggestions for improving this form, write to: CMS, 7500 Security No.: N2-14-26, Baltimore, Maryland 21244-1850. American LegalNet, Inc. www.USCourtForms.com