TX HHS Form H1263-A. Certification of Medical Necessity - Durable Medical Equipment or Other IME

The Certification of Medical Necessity - Durable Medical Equipment or Other IME (Form H1263-A) helps patients in nursing facilities receive a deduction from their income for medically necessary items. This form is used to certify the medical necessity of prosthetic devices, walking aids, special shoes or support for feet, and other durable medical equipment.

This form requires the attending practitioner's certification that the patient required the specified item as a matter of medical necessity. The practitioner must sign and date the form, providing their name and address. The form also includes instructions on when to use it: when determining the amount the patient must pay for care in a nursing facility.

To complete this form, attending practitioners should follow these key guidelines:

• Certify that the patient required the specified item as a matter of medical necessity
• Sign and date the form with their name and address
• Return the completed form in the postage-paid envelope