For Certificate of Medical Necessity:
Does the patient (Yes or No)...
Have permanent non-function or disease of the structures that normally permit food to reach or be absorbed from the small bowel?
Require tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient's overall health status?
Have a documented allergy or intolerance to semi-synthetic nutrients?
Product name(s).
Calories per day for each product?
Days per week administered? (Enter 1 - 7)
-
Method of administration (1 - 4)?
- 1 - Syringe
- 2 - Gravity
- 3 - Pump
- 4 - Does Not Apply