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The form collects participant and patient information, diagnosis details, CPT code, recommended treatment, explanation of medical necessity, and the treatment date range. It includes provider identification, signature, and participant acknowledgment confirming the expense is due to the diagnosed condition and not for general health or cosmetic purposes. Submission is sent to Chard Snyder by fax or mail, with reminders about renewals and documentation.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/letter-of-medical-necessity-form-for-medical-reimbursement-accounts/279535/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/letter-of-medical-necessity-form-for-medical-reimbursement-accounts/279535.png","ImageObject",442,249,{"name":88,"@type":89},"Himbo","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who must complete which sections of the medical necessity letter?","Question",{"text":108,"@type":109},"The licensed health care provider completes the Medical Necessity section, including diagnosis, CPT code, recommended treatment, explanation, and treatment date range. The participant completes the Participant Information and Participant Certification sections after confirming the form was completed by the provider.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information does the provider need to certify medically necessary reimbursement?",{"text":113,"@type":109},"The provider must specify the participant (or spouse/dependent) diagnosis, the specific treatment needed, the length of treatment, and explain how the treatment alleviates the diagnosed condition. The provider also certifies the service/product is medically necessary and not for general good health or cosmetic purposes.",{"name":115,"@type":106,"acceptedAnswer":116},"How should the completed form be submitted to Chard Snyder?",{"text":117,"@type":109},"Send the completed form with the health care provider and participant signatures, plus supporting documentation such as itemized receipts. Submission is available by fax or mail directly to Chard Snyder, and a fax cover page should not be included.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},279535,1790023947,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},687197100911,"https://ap-avatar.wpscdn.com/avatar/a000239b6f1da00475?x-image-process=image/resize,m_fixed,w_180,h_180&k=1785132997149421697","Letter of Medical  \nNecessity Form  \n| \u003Cbr>\u003Cbr>COMPANY INFORMATION |\n| --- |\n| State of Florida |\n\n\n| PARTICIPANT INFORMATION (PLEASE PRINT) |  |  |  |\n| --- | --- | --- | --- |\n| Last Name |  | Primary Phone ( ) - |  |\n| First Name |  | Secondary Phone ( ) - |  |\n| People First ID |  | D(matmdodf/yByyirtyh) / / |  |\n| If the letter of medical necessity is required for claims for your spouse or eligible dependent, please provide the following information: |  |  |  |\n| PATIENT NAME | RELATIONSHIP TO EMPLOYEE |  | DATE OF BIRTH |\n|  |  |  | / / |\n\n\n| MEDICAL NECESSITY (TO BE COMPLETED BY YOUR HEALTH CARE PROVIDER) |  |  |\n| --- | --- | --- |\n| DIAGNOSIS: |  | CPT CODE: |\n| RECOMMENDED TREATMENT: |  |  |\n| EXPLAIN HOW THIS TREATMENT WILL ALLEVIATE THE DIAGNOSIS OR SYMPTOMS OF THE MEDICAL CONDITION: |  |  |\n| DATE RANGE OF TREATMENT | From / / through / / |  |\n\n\n| HEALTH CARE PROVIDER INFORMATION AND CERTIFICATION |  |  |  |\n| --- | --- | --- | --- |\n| Provider Name |  |  |  |\n| Provider Phone | License \\# |  | State |\n| By signing below, I certify that this service or product is medically necessary to treat the specific medical condition described above and is not for general good health or cosmetic purposes. |  |  |  |\n| Licensed Health Care Provider’s Signature: |  | Date\u003Cbr>/ / |  |\n\n\n| PARTICIPANT CERTIFICATION |  |\n| --- | --- |\n| By signing below, I certify that the previous Medical Necessity and Provider Information and Certification sections were completed by the above treating health care provider. The expense I am claiming is not for general good health or cosmetic purposes. The expense is due to the direct result of the medical condition as described above and would not have been incurred but to treat the medical condition as recommended by the health care provider. I also understand that this letter of medical necessity does not guarantee that the expense will be reimbursed under my plan. |  |\n| Participant Signature (required) | Date\u003Cbr>/ / |\n\n\n| SEND THIS FORM TO CHARD SNYDER |  |  |\n| --- | --- | --- |\n| Send the completed form with the signature of the health care provider and participant to Chard Snyder using one of the following: | 􀀻 Fax:\u003Cbr>􀀻 Mail: | 888.245.8452 (Please DO NOT include a fax cover page.)\u003Cbr>PO Box 618, Fort Washington, PA 19034 |\n\nSOF Medical Necessity Form v5 .18  \nLetter of Medical Necessity Instructions  \nUnder Internal Revenue Service rules, some health care services and products are only eligible for reimbursement from your health care FSA when your licensed health care provider (provider) certifies that they are medically necessary. The expense also would not have been incurred but for the direct result of treating the specific diagnosed medical condition. Your provider must indicate your (or your spouse’s or dependent’s) specific diagnosis, the specific treatment needed, the length of treatment, and how this treatment will alleviate your medical condition.  \nChard Snyder has developed this form to assist you and your provider in providing the information we need in order to process your claim. Your provider can also submit a statement on his or her letterhead as long as the  \nletter includes all of the information on this form. (This form is not used for reimbursement of over-the-counter medications. Those items require a doctor’s prescription.)  \nFor fast and accurate processing of your reimbursement request, please make sure to include this letter of medical necessity form or your provider’s letter and itemized receipts or other documentation. If you are claiming membership to a health club, you must not already be a member of a health club and will need to submit documentation showing the membership was obtained after your provider’s recommendation. The reimbursement request claim form can be found on the Chard Snyder website. Please be sure to print the requested information clearly on all documentation submitted.  \nPlease note: If your treatment extends beyond the time period listed","cbCaibuYXw0oV3Pa","https://ap.wps.com/l/cbCaibuYXw0oV3Pa","pdf",187834,"English","# COMPANY INFORMATION\n# PARTICIPANT INFORMATION (PLEASE PRINT)\n# MEDICAL NECESSITY (TO BE COMPLETED BY YOUR HEALTH CARE PROVIDER)\n# HEALTH CARE PROVIDER INFORMATION AND CERTIFICATION\n# PARTICIPANT CERTIFICATION\n# SEND THIS FORM TO CHARD SNYDER\n## Submission instructions\n## Fax and mail details\n## Contact information","[{\"question\":\"Who must complete which sections of the medical necessity letter?\",\"answer\":\"The licensed health care provider completes the Medical Necessity section, including diagnosis, CPT code, recommended treatment, explanation, and treatment date range. The participant completes the Participant Information and Participant Certification sections after confirming the form was completed by the provider.\"},{\"question\":\"What information does the provider need to certify medically necessary reimbursement?\",\"answer\":\"The provider must specify the participant (or spouse/dependent) diagnosis, the specific treatment needed, the length of treatment, and explain how the treatment alleviates the diagnosed condition. The provider also certifies the service/product is medically necessary and not for general good health or cosmetic purposes.\"},{\"question\":\"How should the completed form be submitted to Chard Snyder?\",\"answer\":\"Send the completed form with the health care provider and participant signatures, plus supporting documentation such as itemized receipts. Submission is available by fax or mail directly to Chard Snyder, and a fax cover page should not be included.\"}]","Letter of Medical Necessity Form for Medical Reimbursement Accounts | PDF",1789522553]