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Click ‘Get Form’ to open the letter of medical necessity in our platform.
Begin by entering the 'Date' at the top of the form. This is essential for tracking the validity of your submission.
Fill in the 'Employee Name' and 'SSN/EID' fields accurately, as this information identifies you within your health plan.
Next, provide the 'Patient Name' and their specific 'Diagnosis'. This section is crucial for establishing medical necessity.
Enter the relevant 'CPT Code', which corresponds to the treatment or service being requested.
In the body of the letter addressed to ASI, describe the recommended treatment, how it alleviates symptoms, and its duration. Be clear and concise.
Finally, ensure that your healthcare provider signs off on the document by filling in their name, license number, and contact information before submitting.

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What is an example of medical necessity in a HSA letter?

I am writing on behalf of my patient, [Patient Name], to document the medical necessity to treat their [Diagnosis] with [Product Name]. This letter serves to document my patients medical history and diagnosis and to summarize my treatment rationale. Please refer to the [List any Enclosures] enclosed with this letter.

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