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CERTIFICATE OF MEDICAL NECESSITY
Provider Certification of Medical Necessity for Transportation Attendant Form
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Form: Certificate of Medical Necessity for a Motorized Wheelchair, Custom or Standard (DHS 6181-B)
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Iowa Senior Health Insurance Information Program & Medicare Patrol - Wheelchair scams are common type of durable medical equipment (DME) fraud. Mechanical and motorized wheelchairs can assist a beneficiary who has a
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Patients Name___________________________________________________________Birth Date_____/______/______ Sex______Height_________W
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Medicaid Handbook Transmittal Letter (MHTL) No
CERTIFICATION OF NECESSITY FOR TRANSPORTATION BY WHEELCHAIR VAN
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CERTIFICATION OF MEDICAL NECESSITY FOR AMBULANCE TRANSPORTATION
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Power Wheelchair Coverage Overview
Ramps Medical Necessity Guideline
