Kentucky Medicaid's home health program uses MAP 248 to certify that disposable medical supplies provided through a home health agency are essential to the recipient's medical needs. The agency lists each supply by HCPCS code, quantity and dates, and the physician, APRN or PA certifies the patient requires them. The agency keeps the signed form.
The home health agency fills in agency and recipient information and the supply lines. The physician, APRN or PA marks the anticipated duration of need and signs with NPI, address and date.
Download the current version from the source each time; forms change without notice.
Certification for Disposable Medical Supplies
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Every six months. The form states it must be signed and dated by the physician, advanced practice registered nurse or physician assistant every six months, and its longest duration-of-need option is 4 to 6 months.
A physician, advanced practice registered nurse or physician assistant. The signer prints their name, signs, adds their NPI and address, and dates the form, certifying that the patient requires the supplies listed.