Claim Documentation Divider Sheets
CGS has created the Divider Sheets Tool to assist you in submitting the different types of documentation needed to support your claim. Simply select the type of documentation you are submitting from our list of items below. Then print the pre-designed divider sheet and place it in front of the document(s) that will be submitted for review.
- Advance Beneficiary Notice (ABN)
- Certificate of Medical Necessity (CMN)/DME Information Form (DIF)
- Certifying Physician Statement
- Face-to-face Medical Record of Physical Examination
- Foot Examination
- Home Assessment
- Medical Record that Documents Patient's Condition
- Medical Records: Documentation of Continued Need
- Medical Records: Documentation of Continued Use
- Medical Records: Laboratory/Test Results
- Physician Signature Attestation
- Proof of Delivery
- Refill Request
- Repairs/Replacement Information
- Sleep Physician Credentials
- Standard Written Order
- Supplier Attestation Statement
- Written Order Prior to Delivery
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