Ohio Medicaid uses this one-page certificate of medical necessity to document why an individual needs incontinence garments and related supplies, which items, and how many per month. The supplier can fill in the identifying details and transcribe the certification, but only the prescriber can sign the attestation. It covers initial certifications, changes and renewals.
The supplier may complete the identifying information and transcribe the certification section, including diagnosis codes, items and quantities. The prescriber must complete the attestation, signing and dating it.
Download the current version from the source each time; forms change without notice.
Certificate of Medical Necessity: Incontinence Items
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.
Partly. The form says the identifying information may be completed by the provider and the certification section may be transcribed by the provider. The attestation must be completed by the prescriber, who signs and dates it to confirm the certification information is true, correct and complete.
The form notes that providing or paying for equipment and supplies used by a resident of a long-term care facility is the facility's responsibility. Suppliers should confirm where the individual lives before relying on this certificate for a long-term care facility resident.
One of three: initial certification, change, or renewal/continuation. The certification section then records diagnosis codes, the assessment date, the starting date for dispensing, the type of incontinence, the length of need and each item with its monthly quantity.