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Medicare Forms
CMN Forms
Medicare forms are available for downloading below.
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Physician information for Power Mobility Devices (PMDs)
Read this document if you plan on applying for Medicare coverage of a powered device such as a scooter or power wheelchair: Power Mobility Information Certificate of Medical Necessity (CMN) | These forms can be downloaded and printed.
They are used by the Durable Medical Equipment Regional Carriers (DMERCs).
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| You must have Adobe Acrobat installed to view them. | If you don't have Adobe Acrobat click here to download it. It's Free!
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The following table indicates the newly revised DME MAC CMN Forms:
DME FORM # | HCFA FORM # | DESCRIPTION OF FORM |
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n/a | CMS-R-131-G | Advanced Beneficiary Notice | 01.02B | CMS 484 | Oxygen | |
| 04.04B | CMS 846 | Pneumatic Compression Devices | | 04.04C | CMS 847 | Osteogenesis Stimulators | | 06.03B | CMS 848 | Transcutaneous Electrical Nerve Stimulator (Tens) | | 07.03A | CMS 849 | Seat Lift Mechanism | | 11.02 | MS 854 | CMN - Continuation Form
| | 09.03 | CMS 10125 | External Infusion Pumps | | 10.03 | CMS 10126 | Enteral and Parenteral Nutrition |
Many products no longer require a CMN Form. Manual wheelchairs, power wheelchairs, scooters (POVs), hospital beds, support surface, nebulizers, CPAP, no longer require a CMN Form.
Helpful HCPCS Codes:
Underarm crutch: E0114
Forearm crutch: E0110
Shower char/no back: E0245
Shower chair w/back: E0240
Jr. rollator/4 wh: E0143 + E0156
3 wh/rollator: E0143
Bariatric roll/550lbs: E0149 + E0156
Trapeze bar: E0940
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