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Medicare forms are available for downloading below.
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).
You must have Adobe Acrobat installed to view them.
If you don't have Adobe Acrobat click here to download it. It's Free!
The following table indicates the newly revised DME MAC CMN Forms:
DME FORM #
HCFA FORM #
DESCRIPTION OF FORM
| Advanced Beneficiary Notice|
|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