Sample Certificate of Medical Necessity

This is what a typical Certificate of Medical Necessity (CMN) looks like. This particular example documents the medical need for a lift chair mechanism (Medicare covers the mechanism, by the way, not the whole chair). Your Durable Medical Equipment supplier will usually complete the Medical Necessity form for the kind of equipment the patient requires and submit it for the physician's signature. They then coordinate submitting the document and any other information Medicare may ask for. The patient or caregiver should not have to get personally involved with submitting a Certificate of Medical Necessity.

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