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Claimly Podiatry Practice

Create Certificate of Medical Necessity

Patient Information

Patient Name *

Date of Birth *

Medicare ID

DME Information

DME Code *

Estimated Length of Need (Section C) *

Diagnosis Codes *

Clinical Documentation

Biomechanical Findings *

Functional Limitations *

Medical Necessity Statement *

Physician Certification

Physician Name *

NPI Number *

Signature Date

“I certify that this patient has been examined and meets medical necessity criteria”