I certify that I am the physician/practitioner identified on this form. I have reviewed the Physician’s Written Order. Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information is true, accurate and complete, to the best of my knowledge. I certify I am qualified, under CMS guidelines, to sign and prescribe medical equipment and supplies. I certify that the patient/caregiver is capable and has successfully completed training or will be trained on the proper use of the products prescribed on this Written Order. The patient’s record contains supporting documentation that substitutes the utilization and medical necessity of the products listed and physician notes and other supporting documentation will be provided to cCormick upon request. I understand any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability. A copy of this order will be retained as part of the patient’s medical record.