Get a Letter of
Medical Necessity

LETTER OF MEDICAL NECESSITY Date: ________________ To Whom It May Concern, I am writing to certify that [PRODUCT NAME] is medically necessary for my patient: Patient Name: ________________________________ Date of Birth: ________________________________ Diagnosis: __________________________________ ICD-10 Code: ________________________________ Medical Justification: The above-named product is medically necessary for the treatment, mitigation, or prevention of the patient's diagnosed condition. This recommendation is based on my clinical evaluation and is intended to: [ ] Treat a specific medical condition [ ] Alleviate symptoms of a diagnosed condition [ ] Prevent a condition from worsening [ ] Aid in recovery from illness or injury Specific Medical Benefit: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ This item is not for general health or cosmetic purposes. It is a necessary component of the patient's treatment plan. Duration: This letter is valid for 12 months from the date of signature. Provider Information: Signature: ________________________________ Print Name: ________________________________ Credentials: ________________________________ NPI Number: ________________________________ Practice Name: ________________________________ Phone: ________________________________ Address: ________________________________ Date Signed: ________________________________