[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-284320-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-284320-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","pa-group-letter-of-medical-necessity-form","P&A Group - Letter of Medical Necessity Form","","This document serves as an official Letter of Medical Necessity form for the P&A Group Flexible Spending Account (FSA) plan. It is intended for employees to obtain verification from a physician for expenses that require medical documentation for reimbursement eligibility, such as massages, gym memberships, or weight loss programs. The form includes specific fields for patient and employee information, physician diagnosis, treatment descriptions, and provider certification. Instructions for submission via fax, email, or mail are provided.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/pa-group-letter-of-medical-necessity-form/284320/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/pa-group-letter-of-medical-necessity-form/284320.png","ImageObject",442,249,{"name":42,"@type":43},"Bulrr","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-26","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",10,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What is the purpose of this form?","Question",{"text":63,"@type":64},"This form is used to confirm that specific expenses, such as gym memberships or weight loss programs, are medically necessary for the treatment of a diagnosed medical condition, thereby making them eligible for FSA reimbursement.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Can this form be used for over-the-counter medications?",{"text":68,"@type":64},"No, this form is not to be used for the reimbursement of over-the-counter medications, which require a separate doctor's prescription under the Health Care Reform Act.",{"name":70,"@type":61,"acceptedAnswer":71},"How long is the signed form valid?",{"text":72,"@type":64},"The form is valid for one year from the date of the physician's signature.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},284320,1790456367,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},5909892115043,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","P&A FSA Letter of Medical Necessity Form  \nCertain Flexible Spending Account (FSA) items are eligible for reimbursement only ifa letter of medical necessity is provided. It must include a diagnosis of a medical condition and state that the expense is necessary to treat the medical diagnosis. 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. This form is valid for one year from the date of signature. (Please note: this form is not to be used for reimbursement of over-the-counter medications. Those items require a doctor’s prescription as part of the Health Care Reform Act.)  \nSign the form and submit it to P&A Group via:  \nFax: (877) 213-8917  \n[E-mail:](E-mail: ncflexclaims@padmin.com)[ ncflexclaims@padmin.com](E-mail: ncflexclaims@padmin.com)  \n[Mail:](Mail: P&A Group Attn: NC FSA Plan)[ P&A Group Attn: NC FSA Plan](Mail: P&A Group Attn: NC FSA Plan)  \n17 Court Street Suite 500  \nBuffalo, NY 14202  \nEmployee Information  \nEmployee Name:    \nPatient Name (if different than above):    \nThis section must be completed by the attending physician to confirm if treatment is necessary for a specific medical condition.  \nPlease diagnose the medical condition being treated:  \nDescribe the required treatment:    \nI 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.  \nProvider Signature:  Date:    \nProvider Name: Provider License \\#: Provider Telephone Number:  \n     ( )   \nIf you have any questions please contact NCFlex Customer Service at (866) 916-3475.  \nThe benefits you deserve.","cbCaipfKFtzMp63e","https://ap.wps.com/l/cbCaipfKFtzMp63e","pdf",40689,"English","# P&A FSA Letter of Medical Necessity\n## Submission Instructions\n## Employee Information\n## Physician Attestation Section","[{\"question\":\"What is the purpose of this form?\",\"answer\":\"This form is used to confirm that specific expenses, such as gym memberships or weight loss programs, are medically necessary for the treatment of a diagnosed medical condition, thereby making them eligible for FSA reimbursement.\"},{\"question\":\"Can this form be used for over-the-counter medications?\",\"answer\":\"No, this form is not to be used for the reimbursement of over-the-counter medications, which require a separate doctor's prescription under the Health Care Reform Act.\"},{\"question\":\"How long is the signed form valid?\",\"answer\":\"The form is valid for one year from the date of the physician's signature.\"}]","P&A Group - Letter of Medical Necessity Form | PDF",1789628585]