Cms-854 -- Continuation Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0679

CERTIFICATE OF MEDICAL NECESSITY
CMS-854 — CONTINUATION FORM
PATIENT NAME

SECTION C

DME 11.02

PATIENT HICN

Narrative Description of Equipment and Cost (continued)

(1) Narrative description of all items, accessories and options ordered; (2) Supplier's charge; and (3) Medicare Fee Schedule Allowance for each
item, accessory and option. (see instructions on back.)

SECTION D

PHYSICIAN Attestation and Signature/Date

I certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of Medical
Necessity (including charges 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 section may subject me to civil or criminal liability.

PHYSICIAN’S SIGNATURE_________________________________________________________________________ DATE _____/_____/_____
Form CMS-854 (09/05) EF 08/2006

INSTRUCTIONS FOR COMPLETING THE CERTIFICATE OF MEDICAL NECESSITY
SECTION C CONTINUATION FORM (CMS-854)
SECTION C:

(To be completed by the supplier)

NARRATIVE
DESCRIPTION OF
EQUIPMENT & COST:

Provide (1) a narrative description of the item(s) ordered, as well as all options, accessories; (2) the product, model and
serial number of the product being delivered (if applicable); (3) the supplier’s charge for each item, option, accessory; and
(4) 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.

PHYSICIAN SIGNATURE
AND DATE:

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

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 12 minutes per response, 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 concerning the accuracy of the time estimate or suggestions for improving
this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.

DO NOT SUBMIT CLAIMS TO THIS ADDRESS. Please see http://www.medicare.gov/ for information on claim filing.
Form CMS-854 (09/05) INSTRUCTIONS EF 08/2006