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Medicare Forms

Medicare forms are available for downloading below.

Certificate of Medical Necessity (CMN)
These forms can be downloaded and printed.
They are used by the Durable Medical Equipment Regional Carriers (DMERCs)

The following table indicates the newly revised DME MAC CMN Forms:
DESCRIPTION OF FORM
DME FORM #HCFA FORM #
n/aCMS-R-131-GAdvanced Beneficiary Notice
04.04BCMS 846Pneumatic Compression Devices
04.04CCMS 847Osteogenesis Stimulators
06.03BCMS 848Transcutaneous Electrical Nerve Stimulator (Tens)
07.03ACMS 849Seat Lift Mechanism
11.02MS 854CMN - Continuation Form
09.03CMS 10125External Infusion Pumps
10.03CMS 10126Enteral 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