Letter Of Medical Necessity Template Page 2

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The Federal FSA Program
Letter of Medical Necessity (LMN)
By submitting this LMN you certify that the expenses you are claiming are a direct result of the medical
condition described below, and you would not incur the expenses you are claiming if you were not treating this
medical condition.
You only need to submit this form, or your provider’s letter containing the same information, with the first
claim you submit for the service or product. However, if the treatment extends beyond the time period listed,
you must submit a form or physician letter covering the new time period. You must submit a new LMN each
year – they cannot be approved indefinitely.
Submitting this form does not guarantee that the expense will be reimbursed.
Note: All fields below are required.
Date:
Email Address:
Account Holder’s Name:
Account Holder’s UserID:
Patient’s Name:
Diagnosis:
CPT Code:
Recommended Treatment:
How will the treatment alleviate the diagnosis?
Begin Date of Treatment:
End Date of Treatment:
(not to exceed 12 months)
Provider Signature:
Provider Name:
Provider Address:
Provider License #:
Provider Telephone #:
Please fax this form to 1‐866‐643‐2245 (toll‐free) or 1-470-865-6717. If you have questions, contact an FSAFEDS
Benefits Counselor, toll‐free, at 1‐877‐FSAFEDS (372‐3337), TTY: 1‐800‐952‐0450, Monday through Friday,
.
. until 9:00
.
., Eastern Time.
9:00
A
M
P
M
Note: FSAFEDS’ role is to make sure that the proper documentation is submitted for reimbursement under the
Plan. FSAFEDS will review this letter of medical necessity for completeness and to ensure that the treatment
meets IRS guidelines and FSAFEDS eligibility standards.
The Federal FSA Program
FSAFEDS Program  PO Box 36880  Louisville, KY 40233 
 1‐877‐FSAFEDS (372‐3337)
05.15

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