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The document is a Letter of Medical Necessity form required for services or products classified as 'Maybe Expense' or 'Ineligible Expense' under IRC Sec 213 (d) (1). It must be completed by a medical care provider to certify that the service or product is medically necessary for the patient. The form includes sections for patient and participant information, details about the medical condition, recommended treatment, and practitioner certification. To receive reimbursement, participants must submit this form along with a Health Care FSA claim form and supporting documentation.

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