Form Dvha 60 - Medical Necessity Form (Mnf) printable pdf download

DVHA 60

DEPARTMENT OF VERMONT HEALTH ACCESS

VERMONT MEDICAID

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MEDICAL NECESSITY FORM (MNF)

ORTHOTICS, PROSTHETICS, MEDICAL SUPPLIES & EQUIPMENT FOR IN-HOME USE

All claims for supplies and equipment require a written physician order. Copies of the order must be kept in

the patient record by both the physician and DME suppIier. It is the responsibility of the ordering physician to

complete or review this Medical Necessity Form (MNF) and provide adequate documentation/information of

the plan of treatment. The physician then gives this information either to the patient (to be taken to the DME

supplier of choice) or directly to the DME supplier. The DME supplier must be enrolled in Vermont Medicaid.

Section A: (must be completed or reviewed and signed by ordering physician)

1.Patient’s Name______________________ DOB___/___/___Medicaid ID#__________________

Section A (must be completed or reviewed and signed by ordering physician)

2.Diagnoses____________________________________________________

3.Place of service: Is(are) the ordered item(s) to be used in the patient’s home? Yes___ No_____

Name and address of other facility_________________________________________________

4.Functional Level (check all that apply): Ambulatory___Non-ambulatory___Bed-ridden___

Confined to wheelchair____Able to transfer self___Ambulatory with assistance___ assist of

what/whom__________

Able to use regular bathroom facilities____if not, why?_______________________________

5. HCPCs Code and

Initial

Purpose or Use of Item

Expected Length

# Per

Name of Item Ordered

Order Date

of Need (months)

Month

6.Date of Related Incident______/______/______Date of Related Surgery_____/_____/_____

I CERTIFY THAT THE ITEM(S) PRESCRIBED ABOVE IS(ARE) A NECESSARY PART OF THE

COURSE OF TREATMENT AND NOT FOR PRECAUTIONARY OR STANDBY PURPOSES NOR

FOR CONVENIENCE OR COMFORT.

7.Physician’s Name & Address____________________________________________________________

8.Physician’s Signature____________________________________Date Signed___________________

9.Physician’s Medicaid Provider #____________________________Phone#_______________________

Physician: Please give this form to the recipient or send directly to supplier. Do not send to the Department of

Vermont Health Access or to HP.

See back for DME information and instructions

Form Dvha 60 - Medical Necessity Form (Mnf)