Medicare Forms
CMN 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/a CMS-R-131-G 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