Letter of Medical Necessity
Please complete ALL fields below with as much detail as possible. After receipt, we will submit to our Medical Director, who will create the letter on your behalf. We will then email the letter to you.
Patient Name
Your answer
Patient Age
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Patient Birthdate
MM
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DD
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YYYY
Insured Person's Name
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Insured Person's Birthdate
MM
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DD
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YYYY
Medical Insurance Provider Name
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Insurance ID number
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Insurance Group Number (if applicable)
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How patient is related to Insured person (self, child, spouse, other)
Your answer
Symptoms: What, how long...
Your answer
Previous treatments: What, how often...
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Implications of diagnosis (Time from work, school, etc.)
Your answer
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