Letter of Medical Necessity (LMN)
Letter of Medical Necessity
Structured for FSA/HSA Reimbursement Approval
Form Instructions:
Under Internal Revenue Service (IRS) rules, certain expenses are eligible for health care account reimbursement only when accompanied by a Letter of Medical Necessity. When required, submit this completed form with your claim submission as additional documentation.
Please keep a copy of all submitted documents for your records.
Note: If a claim requires a Letter of Medical Necessity, the claim will not be paid until the Letter of Medical Necessity Form and any required supporting documentation is received. An updated
Letter of Medical Necessity is required each year. This form is valid for one year from the date of signature. This form is subject to review and does not guarantee approval.
Account Holder Name: _______________________________________
Patient Name (if different from Account Holder): ______________________________
To be completed by physician:
Describe the diagnosed medical condition being treated:
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Describe the required treatment:
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This treatment is medically necessary to treat the specific medical condition noted above. This treatment is not in any way for general health; and is not for cosmetic purposes to improve appearance.
Provider Signature: ____________________________ Date: ____ / ____ / ______
Provider Name (Please Print): _______________________________________
Provider License #: ____________________________
Provider Telephone Number: ____________________________
How to Submit:
Include this completed form with your receipt when submitting your reimbursement request to your FSA/HSA provider.
This form is intended to support FSA/HSA reimbursement eligibility for medically necessary wellness tools or services.
It must be completed by a licensed medical provider and submitted with the patient's reimbursement request.
Valid for 12 months from the date of provider signature unless otherwise noted.