Try for free

Alaska Medicaid CMN General Prescriber Page

Alaska Medicaid requires this prescriber page of the Certificate of Medical Necessity when a durable medical equipment supplier requests service authorization for equipment or supplies. The ordering practitioner documents the diagnoses, how long the item is needed and why it is medically necessary. The supplier pairs it with its own supplier page and sends both with the DMEPOS service authorization request to the Medicaid fiscal agent.

Who completes it

The ordering physician, physician assistant, nurse practitioner or audiologist completes and signs it. Section C may be written by an attending specialist such as a PT, OT, speech-language pathologist or registered dietitian, who then signs as well; the DME supplier may not complete anything from Section B onward.

Submitting and payment

How to submit it
The completed page is given to the DME supplier, which submits it with the supplier page and the DMEPOS service authorization request to the Alaska Medicaid fiscal agent.
Who pays
The form sets no fee for the prescriber; it supports the supplier's service authorization for the equipment or supplies.

Good to know

  • Section B asks for the date of the last related visit, the prescription start date, up to four diagnosis codes and the estimated length of need in months, with 99 meaning lifetime.
  • Section C needs a medical justification tied to the member's specific diagnosis plus a plan listing each item or service. Supporting documentation can be attached.
  • Item-specific certificates exist for enteral nutrition, incontinence supplies and home oxygen, with separate oxygen versions for members age 5 and older, under 5, and 5-year replacement.
  • The current version is dated 09/23/2024. The state distributes it as a certified, digitally signed PDF, which some PDF tools will not let you edit.

Get the official form

Download the current version from the source each time; forms change without notice.

Alaska Medicaid Certificate of Medical Necessity, General Prescriber Page

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who can sign the Alaska Medicaid CMN prescriber page?

The ordering physician, physician assistant, nurse practitioner or audiologist signs to confirm they are the ordering provider named in Section A. If an attending specialist such as a physical therapist, occupational therapist, speech-language pathologist or registered dietitian wrote the clinical assessment in Section C, that specialist must also sign with their title and the date.

Can the DME supplier fill out the Alaska CMN prescriber page?

Only partly. The form states that no information from Section B onward may be completed by the DME supplier. That covers the diagnoses, prescription start date, length of need, clinical justification, plan and signatures. The supplier records its own details on the separate CMN General Supplier Page.