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The provider certifies the service is medically necessary and not for general good health or cosmetic purposes. The participant completes a certification regarding the medical basis of the claim and acknowledges reimbursement is not guaranteed. Submission guidance explains fax or mail to Chard Snyder and key reminders for faster processing.",{"@graph":63,"@context":119},[64,80,102],{"@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-v921-instructions/279672/",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-v921-instructions/279672.png","ImageObject",442,249,{"name":88,"@type":89},"Rhys","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information must the company and participant provide on this form?","Question",{"text":109,"@type":110},"Enter company information and participant details including names, contact information, SSN (or alternate employee ID), date of birth, and email address. If the claim involves a spouse or eligible dependent, include the patient name, relationship, and patient date of birth.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What does the medical provider need to complete?",{"text":114,"@type":110},"The provider must provide the diagnosis, CPT code (if applicable), recommended treatment, an explanation of how the treatment alleviates the condition, and the date range of treatment. The provider must also sign, include a license number, and date the certification.",{"name":116,"@type":107,"acceptedAnswer":117},"How should the completed form be submitted to Chard Snyder?",{"text":118,"@type":110},"Submit by fax or mail. Fax to Local 513.459.9947 or Toll-Free 888.245.8452 (do not include a fax cover page), or mail to P.O. Box 249, Fort Washington, PA 19034. The form should be sent together with provider documentation and itemized receipts as noted in the instructions.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},279672,1789525266,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":9},687207024643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Letter of Medical Necessity Form  \nSubmit documentation on your Chard Snyder online account or on the Chard Snyder Mobile App for quickest processing and reimbursement. Paper forms can be submitted by fax or mail, but expect longer processing times for these methods.  \n\n| Company Information (PLEASE PRINT) |  |\n| --- | --- |\n| Company Name | Division (if applicable) |\n\n\n| Participant Information (PLEASE PRINT) |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Last Name |  |  | Primary Phone |  |\n| First Name |  |  | Secondary Phone |  |\n| SSN /\u003Cbr>(or Alternate Employee ID) | Date of Birth\u003Cbr>(mm/dd/yyyy) |  | Email Address\u003Cbr>(For Account Notifications) |  |\n| Street Address |  |  |  |  |\n| City |  |  | State | Zip |\n| If the letter of medical necessity is required for claims fora spouse or eligible dependent, please provide the following information |  |  |  |  |\n| Patient Name |  | Relationship |  | Date of Birth |\n|  |  |  |  |  |\n\n\n| Medical Necessity (TO BE COMPLETED BY YOUR MEDICAL 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| 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| Provider’s Signature: |  | Date |  |\n\n\n| Participant Certification |  |\n| --- | --- |\n| By signing below, I certify that the Medical Necessity and Provider Information and Certification sections were completed by the above treating physician. The expense I am claiming is not for general good health or cosmetic purposes but is the direct result of the medical condition as described above by the healthcare 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 |\n\n\n| SEND THIS FORM TO CHARD SNYDER |  |  |\n| --- | --- | --- |\n| Please submit this form to Chard Snyder by one of the two methods listed to the right | Fax: | Local 513.459.9947 / Toll-Free 888.245.8452 (Please DO NOT include a Fax Cover Page) |\n|  | Mail: | P.O. Box 249, Fort Washington, PA 19034 |\n\nMedical Necessity Form v9.21  \nLetter of Medical Necessity Instructions  \n1. Complete all company and participant information on the front page (please print/type) . NOTE: Please include your e-mail address to receive an automatic e-mail notification whenever a claim is entered into our system and when a reimbursement is approved for you to receive payment  \n2. Ask your medical provider to complete the section titled “Medical Necessity” or submit a statement on his or her letterhead providing the information below:  \n􀀻 The patient’s name  \n􀀻 The specific diagnosis  \n􀀻 The specific treatment needed  \n􀀻 The length of treatment  \n􀀻 How this treatment will alleviate the medical condition  \n3. Your provider MUST sign and date the form or statement provided  \n4. You MUST sign and date the “Participant Certification” section on the front of this page  \n5. Fax or Mail this form with your claim directly to Chard Snyder:  \n􀀻 Fax: Local 513.459.9947 / Toll-Free 888.245.8452 (Please DO NOT include a Fax Cover Page)  \n􀀻 Mail: P.O. Box 249, Fort Washington, PA 19034  \n6. If you have questions please contact us:  \n􀀻 Call Customer Service: 513.459.9997 | 800.982.7715  \n􀀻 Visit our Website: www.chard-snyder.com  \n7. Important Reminders:  \nTo ensure your claim is processed as soon as possible, and avoid delays:  \n􀀻 Include this letter of medical necessity form or your provider’s letter and itemized receipts with your original claim  \n􀀻 Only health club memberships obtained after your heal","cbCaihduiIyN7S4t","https://ap.wps.com/l/cbCaihduiIyN7S4t","pdf",648456,"English","# Letter of Medical Necessity Form\n## Company Information\n## Participant Information\n## Medical Necessity (Medical Provider)\n## Provider Information and Certification\n## Participant Certification\n## Submit This Form to Chard Snyder","[{\"question\":\"What information must the company and participant provide on this form?\",\"answer\":\"Enter company information and participant details including names, contact information, SSN (or alternate employee ID), date of birth, and email address. If the claim involves a spouse or eligible dependent, include the patient name, relationship, and patient date of birth.\"},{\"question\":\"What does the medical provider need to complete?\",\"answer\":\"The provider must provide the diagnosis, CPT code (if applicable), recommended treatment, an explanation of how the treatment alleviates the condition, and the date range of treatment. The provider must also sign, include a license number, and date the certification.\"},{\"question\":\"How should the completed form be submitted to Chard Snyder?\",\"answer\":\"Submit by fax or mail. Fax to Local 513.459.9947 or Toll-Free 888.245.8452 (do not include a fax cover page), or mail to P.O. Box 249, Fort Washington, PA 19034. The form should be sent together with provider documentation and itemized receipts as noted in the instructions.\"}]","Letter of Medical Necessity Form - v9.21 - Instructions | PDF"]