Medical Necessity Form
This section must be filled by the participant
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Patient Name
First Name
Last Name
Participant Name
First Name
Last Name
Employer of Participant
This section must be filled by licensed practitioner
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Medical Condition
Recommended treatment description
Frequency & dosage
Treatment Duration
If it is chronic, please indicate "lifetime"
Name of Licensed Practitioner
First Name
Last Name
I, licensed practitioner, agree with the following statement.
I certify that this service or product is medically necessary to treat the specific medical condition described above and is not in any way for general health or for cosmetic purposes.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Licensed Practitioner
Submit
Should be Empty: