Letter of Medical Necessity
Under
Internal Revenue Service (IRS) rules, some health care services and products
are eligible for reimbursement from your Health Care Flexible Spending Account
(HCFSA) when your doctor or other licensed health care provider certifies that
they are medically necessary. Your
provider must indicate your specific diagnosis, the specific treatment needed,
and how this treatment will alleviate your medical condition.
Our
Clinic has developed this letter to assist you and your primary care physician
in providing the information required by your employer and/or the IRS. Your primary care provider can also submit a
statement on his or her letterhead, as long as the letter includes all of the
information on this form.
“My patient,
___________________________________________ has the following (enter patients’ full name)
active medical conditions:
These conditions are in part or in
whole due to this patient’s excess body weight or
obesity. Medical weight management
treatment is medically necessary to improve this
patients’ health status and reduce her risk of morbidity in the future.”
Sincerely,
____________________________
(Provider’s
signature)
____________________________
(Provider’s
printed full name & title)
____________________________
Provider’s
telephone no.