Depending on your plan administrator (like Fidelity, Optum, or HealthEquity), this document may be called a Letter of Medical Necessity (LMN) or a Statement of Medical Necessity (SOMN). They serve the same purpose.
Enter the details below to create a professional, compliant letter for your doctor to sign.
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Not Financial or Medical Advice. This document is a standardized template provided for educational and administrative convenience. It does not guarantee reimbursement. Final approval rests with your plan administrator based on your specific plan documents and IRS regulations.
Date:
To: Benefits Administrator / FSA Plan
From:
I certify that the above-named patient is currently under my care for the treatment of the following medical condition:
Diagnosis:
To treat, mitigate, or prevent this condition, I have recommended the following specific treatment or product:
Recommendation:
Duration of Treatment:
This treatment is medically necessary to alleviate the patient's symptoms and is not for general health, wellness, or cosmetic purposes.
Sincerely,
Provider Name: