VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

CERTIFICATE OF MEDICAL NECESSITY

DURABLE MEDICAL EQUIPMENT AND SUPPLIES
SECTION I RECIPIENT DATA SERVICING PROVIDER
I.D. # I.D. # Note: The CMN can now be used

Name Name in place of DMAS-115. The

D.O.B. Contact Person original requirements for justification

Phone # ( ) Phone # ( ) still apply. Additional questions

SECTION II RECIPIENT INFORMATION have been added to the CMN (pg 1-

2).
Answer all questions that are applicable to DME service being requested. DESCRIPTION/ADDITIONAL INFORMATION:
If answer is yes, you must describe/attach additional information. (Additional space on reverse)
Does patient: YES NO
1. have impaired mobility? ‰ ‰
2. have impaired endurance? ‰ ‰
3. have restricted activity? ‰ ‰
4. have skin breakdown? (Describe site, size,
depth and drainage) ‰ ‰
5. have impaired respiration? (Identify most
recent PO2________/Saturation level _______ ‰ ‰
for patients on oxygen)

6. require assistance with ADL's? ‰ ‰

7. have impaired speech? ‰ ‰
*** 8. a) require nutritional supplements? (If yes,
answer b and c below.) ‰ ‰
b) sole source or primary source (circle one)
c) height _________ weight _____________
IS THE ITEM SUITABLE FOR USE IN HOME, AND DOES THE PATIENT/CAREGIVER DEMONSTRATE WILLINGNESS/ABILITY TO USE THE EQUIPMENT? YES____NO____
Date patient last examined by practitioner

ICD9 Code Clinical Diagnoses Date of Onset

Less than 6 months Greater than 6 months

SECTION III (ADDITIONAL SPACE ON REVERSE)

Begin Length Quantity
Service HCPCS Item Ordered of Ordered/ Frequency of Use*
Date Code Description* Time x1 Month* Justification/Comments/
Needed Calories Per Day

SECTION IV PRACTITIONER CERTIFICATION (MUST BE SIGNED AND DATED BY PRACTITIONER)

I CERTIFY THAT THE ORDERED DME AND SUPPLIES ARE PART OF MY TREATMENT PLAN AND, IN MY OPINION, ARE MEDICALLY NECESSARY.

( )
ORDERING PRACTIONER'S NAME PRACTITIONER'S SIGNATURE* DATE* I.D.# PHONE #
(print)
*Required fields. If any of these fields are blank the CMN is not valid. **Practitioner will be a physician, physician assistant, and a nurse practitioner.
Practitioner’s signature does not guarantee payment unless all documentation requirements are met.
Issuance of a PA does not guarantee payment. Payment is contingent upon all appropriate documentation being readily available for review.
DMAS-352, Revised 7/2010
 ***Complete diet order must be indicated in Section III

DMAS-352, Revised 7/2010

RECIPIENT NAME VMAP #
SERVICING PROVIDER PROVIDER
NAME ID#

DESCRIPTION/ADDITIONAL INFORMATION
SECTION II (continued)

*For Nutritional Supplements assessor must document formula tolerance and tube/stoma site assessment if applicable. This can be documented on the
CMN or in the supporting documentation, signed and dated by the practitioner. ***Complete diet order must be indicated in Section III

SECTION III (continued)

Begin Length *Quantity
Service HCPCS *Item Ordered of Ordered/ Frequency of Use*
Date Code Description Time x1 Month Justification/Comments/
Needed Caloric Order Per Day

SECTION IV PRACTITIONER CERTIFICATION (MUST BE SIGNED AND DATED BY PRACTITIONER)

I CERTIFY THAT THE ORDERED DME AND SUPPLIES ARE PART OF MY TREATMENT PLAN AND, IN MY OPINION, ARE MEDICALLY NECESSARY.

( )
ORDERING PRACTITIONER'S NAME PRACTITIONER'S SIGNATURE DATE I.D.# PHONE #
(print)

Section I RECIPIENT DATA Section III

• Complete 12-digit recipient identification number • Begin service date (month, day and year)
• Complete recipient full name (last name, first name) • Item ordered description: must be narrative description of item
• Complete full date of birth (month, day, year) ordered (DME vendor may identify by HCPC Code)
• Telephone # (include area code) • Length of Time Needed: length of time item will be needed for all
durable equipment
SERVICING PROVIDER • Quantity ordered: identify quantity ordered; for expendable
• Complete provider number (7-digits) supplies, designate supplies needed for 1 month; if items are
• Complete provider name required greater than 1 month, note time frame in the Length of
• Complete contact identifying person to call if DMAS has questions Time Needed column (if more than one item is needed but not
needed every month then the provider should indicate the
appropriate amount (i.e., 1 per 2 month or 1/2M etc.)
Section II RECIPIENT INFORMATION • Frequency of Use, Justification/Comments: practitioner's order for
• Check ALL boxes that apply frequency of use must be identified
• Identify functional limitations related to recipient and need for DME
service Section IV PRACTITIONER CERTIFICATION
• If requesting oxygen, the results of PO2/Saturation levels must be • Practitioner full name (print)
identified • Must be signed and fully dated by practitioner (NOTE: Attached
• Date last examined by practitioner practitioner prescription will not be accepted in lieu of practitioner
• ICD9 Code (optional) signature/date on this form); IF ORDERS FOR DME SERVICE ARE
• Clinical diagnoses - narrative must be identified. Diagnosis must WRITTEN ON BOTH SIDES OF FORM, PRACTITIONER MUST SIGN/DATE
be related to the item being requested BOTH SIDES OF FORM
• Check appropriate line for date of on-set • Complete practitioner Medicaid provider number (optional)
• Telephone number (include area code)
DMAS-352, Revised 7/2010