[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-280848-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-280848-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","letter-of-medical-necessity-form-medical-necessity-letter-template","Letter of Medical Necessity Form - Medical necessity letter template","","A Letter of Medical Necessity form supports reimbursement for eligible Flexible Spending Account (FSA) items by documenting that an expense is required to treat a specific medical diagnosis. The attending physician must complete and sign sections identifying the healthcare provider, diagnosis details, treatment start and end dates, and required treatment description. 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The letter must include the diagnosis of a medical condition and state that the expense is necessary to treat the medical diagnosis. It must also include the length of treatment. Examples of expenses that are deemed as medically necessary in order to treat a medical condition (and therefore are eligible for reimbursement under the FSA plan) include massages, gym memberships and weight loss programs. Your physician must complete and sign the form below, thereby acknowledging that the medical expense is being used to treat a medical condition. |  |\n| This form is valid for one year from the date of signature. A new form must be submitted annually.\u003Cbr>EMPLOYEE INFORMATION |  |\n| Company Name Employee DOB Employee Last Name Employee First Name Last 4 Digits of SSN or Member ID \\# Patient Last Name (if different than above) Patient First Name (if different than above) |  |\n| \u003Cbr>PHYSICIAN’S DIAGNOSIS\u003Cbr>(This section must be completed by the attending physician to confirm if treatment is necessary for a specific medical condition.) |  |\n| Healthcare Provider Name Provider License No. Healthcare Provider Phone No. Diagnosis Date (mm/dd/yyyy) Treatment Start Date (mm/dd/yyyy) Treatment End Date (mm/dd/yyyy) / / / / / / Please diagnose the medical condition being treated. Describe the required treatment. |  |\n| \u003Cbr>I assert that this treatment is medically necessary to treat the specific medical condition noted above. This treatment is not in any way intended for general health maintenance or cosmetic purposes.\u003Cbr>Healthcare Provider Signature: X Date: / / |  |\n| \u003Cbr>Submit completed form to P&A Group. Fax: (877) 855-7105 Mail: P&A Group 6400 Main Street, Suite 210 Williamsville, NY 14221 |  |\n| HOURS: Monday-Friday, 8:30 a. m. -10:00 p. m. ET | WEB: [www.padmin.com](www.padmin.com) | PHONE: (800) 688-2611 |  |","cbCaiuSn23izDWQd","https://ap.wps.com/l/cbCaiuSn23izDWQd","pdf",64738,"English","# Employee information\n# Physician’s diagnosis\n# Medical necessity assertion and signature\n# Submission details","[{\"question\":\"Who needs to complete and sign the Letter of Medical Necessity form?\",\"answer\":\"The attending physician must complete the physician diagnosis section and sign the form to acknowledge that the medical expense is used to treat a medical condition.\"},{\"question\":\"What information must the physician include in the diagnosis section?\",\"answer\":\"The form requires the diagnosis of the medical condition, a description of the required treatment, and treatment dates including start and end dates.\"},{\"question\":\"How long is the form valid and how often must it be submitted?\",\"answer\":\"The form is valid for one year from the date of signature and must be submitted annually for continued reimbursement eligibility.\"}]","Letter of Medical Necessity Form - Medical necessity letter template | PDF",1789559855]