Form: Physician Certification of Medical Necessity for ...
California Medical License Number: Physician Signature (original): Date: 2 – Injections. PROPubs 5/05. 2 – Orthotic and Prosthetic Appliances. PROPubs 09/15. Title: Form: Physician Certification of Medical Necessity for Therapeutic Diabetic Shoes and Inserts (ortho 1 form) Description: LB pg.1 new (03.08.06) LB pg.1 (07.07.06) new title LB ... ................
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