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Doctors Must Fill Out the CMN Form Below For All Qualified Patients:

1. Enter Diagnosis Codes (ICD-9) in Section B
2. Circle Yes for Questions  1, 6, 7
3. Circle No for questions: 2, 3, 4  (these questions are for accessories only)
4. Question 5 should be anywhere from 6- 8 hours, possibly more.
5. Physician must Sign & Date
6. Fax this form & Equipment order form to attention:

Ralph Coleman @  561-883-1658

ralphcoleman2003@yahoo.com

FOR  THE  CERTIFICATION  OF  MEDICAL  NECESSITY  FORM  PLEASE  CLICK  THE  FOLLOWING  LINK  AND  PRINT:

http://www.freewebs.com/medicalsupply/Medical%20Necessity%20Form%20(CMN).htm

EQUIPMENT  ORDER  FORM

PLEASE  FAX  BACK  TO  ATTENTION  RALPH COLEMAN @:

561-883-1658

Date:_______/_______/________

Patient Name:________________________________________________________________________

Patient Local Address: _______________________________________________________________

Shipping Address if Different from above:_______________________________________________________

Patient Home Phone Number:_______________________________________________________

Date of Birth:_____________________________________________________________________________

Primary Insurance Company:_______________________________________________________

Primary Insurance Membership# :___________________________________________________

Secondary Insurance Company:_______________________________________________________________

Secondary Insurance Membership#:____________________________________________________________

Diagnosis (ICD-9):_____________________________________________________________

Physician's Name:_________________________________________________________________________

Physician's Address:________________________________________________________________________

Physician's UPIN#:________________________________________________________________________

Type of Equipment Ordered:_________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Ralph Coleman

Broward Medical Supply

Ralphcoleman2003@yahoo.com