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EXHIBIT M

EXHIBIT M

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Form: Certificate of Medical Necessity for All Durable Medical Equipment ( DME) (Except Wheelchairs and Scooters) (DHS 6181)Form: Certificate of Medical Necessity for All Durable Medical Equipment ( DME) (Except Wheelchairs and Scooters) (DHS 6181)Form: Certificate of Medical Necessity for a Manual Wheelchair, Standard or Custom (DHS 6181-A)Form: Certificate of Medical Necessity for a Manual Wheelchair, Standard or Custom (DHS 6181-A)Form: Certificate of Medical Necessity for a Motorized Wheelchair, Custom or Standard (DHS 6181-B)Form: Certificate of Medical Necessity for a Motorized Wheelchair, Custom or Standard (DHS 6181-B)Durable Medical Equipment Services Provider Manual Manual Updated 09/01/21 i Number Name Revision Date DHHS 126 Confidential ComDurable Medical Equipment Services Provider Manual Manual Updated 09/01/21 i Number Name Revision Date DHHS 126 Confidential ComForm: Certificate of Medical Necessity for a Power Operated Vehicle (POV) aka Scooter, Standard or Bariatric (DHS 6181-C)Form: Certificate of Medical Necessity for a Power Operated Vehicle (POV) aka Scooter, Standard or Bariatric (DHS 6181-C)PRIOR AUTHORIZATION / DURABLE MEDICAL EQUIPMENT ATTACHMENT (PA/DMEA) COMPLETION INSTRUCTIONS,PRIOR AUTHORIZATION / DURABLE MEDICAL EQUIPMENT ATTACHMENT (PA/DMEA) COMPLETION INSTRUCTIONS,Durable Medical Equipment Services Provider Manual Manual Updated 09/01/21 i Number Name Revision Date DHHS 126 Confidential ComDurable Medical Equipment Services Provider Manual Manual Updated 09/01/21 i Number Name Revision Date DHHS 126 Confidential ComDURABLE MEDICAL EQUIPMENT PRIOR AUTHORIZATION REQUEST FORMDURABLE MEDICAL EQUIPMENT PRIOR AUTHORIZATION REQUEST FORMCERTIFICATE OF MEDICAL NECESSITY FOR A MANUAL WHEELCHAIR, STANDARD OR CUSTOM ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ Yes ❒CERTIFICATE OF MEDICAL NECESSITY FOR A MANUAL WHEELCHAIR, STANDARD OR CUSTOM ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ ❒ Yes ❒Application and Statement of Qualification (DME/DPRE/DAR-T, ODAR-T)Application and Statement of Qualification (DME/DPRE/DAR-T, ODAR-T)Form 04AF001E - 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