Certification of Medical Necessity

1. Complete the form in its entirety by checking all boxes and filling in all spaces that apply to the patient’s current condition.
2. Print AND sign your name.
3. Mark your credentials (i.e. Physician, Registered Nurse, Discharge Planner, etc.).
4. Fax the completed form to our Billing Department at 909.433.3934.

Please note: An incomplete Certification of Medical Necessity may affect our ability to fulfill your request or bill the insurance. If you have any questions about the form or any of its requirements, please call 909.880.0911. Our staff will be happy to assist you.