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