Letter of Medical Necessity (LMN/SOMN) Template
If you want to use your FSA or HSA for "Dual Purpose" items—like vitamins, supplements, massage therapy, or an Oura Ring—you will likely be denied unless you have a specific document.
This document is called a Letter of Medical Necessity (LMN). Some administrators also call it a Statement of Medical Necessity (SOMN). They are the same thing.
The Template
You can copy the text below and paste it into a Word document for your doctor to sign, or download the PDF version.
To: [Benefits Administrator Name]
From: [Physician Name, MD]
Patient: [Patient Name]
Date: [Date]
Subject: Letter of Medical Necessity
This letter is to certify that [Patient Name] is currently under my care for the treatment of [Specific Medical Condition, e.g., Insomnia, Chronic Back Pain, Vitamin Deficiency].
To treat this condition, I have recommended the following:
[Specific Product/Service, e.g., Massage Therapy, Magnesium Supplements]
This treatment is medically necessary to alleviate the patient's symptoms and is not for general health or cosmetic purposes.
Duration of Treatment: [e.g., 12 Months]
Sincerely,
__________________________
[Physician Signature]
[License Number]
Prefer a PDF?
Download PDF Template