Sample Letter Of Medical Necessity

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Letter of Medical Necessity
Flex Spending Accounts (FSA) / Health Reimbursement Arrangement (HRA) /
Health Savings Accounts (HSA)
Under IRS guidelines, some health care products are eligible for (a) reimbursement through an FSA/HRA, or
(b) treatment as a tax-free distribution from an HSA only if it can be shown that the products are medically
necessary. If a dentist has diagnosed a medical condition and recommended a Waterpik® Water Flosser as
treatment or mitigation for the medical condition, under IRS guidelines it should qualify for reimbursement
through an FSA/HRA and for tax-preferred treatment for an HSA. Some plans may restrict reimbursement
beyond the IRS requirements. Dentists: If your patient participates in an FSA, HRA or HSA program, and they
purchase a Waterpik® Water Flosser pursuant to your recommendation to treat or mitigate a medical condition
you have diagnosed, your patient should be eligible for reimbursement or tax-preferred treatment under that
FSA, HRA or HSA (subject to any additional limitations or conditions of the plan).
Completed by Patient:
I certify that the expenses I am claiming are a direct result of the medical
Patient:
condition described below, and that I would not incur this expense if I were not
Mail or Fax this
treating or mitigating this medical condition.
form (and a copy
of your receipt)
Patient Name:
______________________________
to your
FSA/HRA
Participant Name:
______________________________
Administrator
(or retain for
Participant’s Employer:
______________________________
your HSA
records).
Member Number:
______________________________
Diagnosis: Gingivitis.
Treatment: Waterpik® Water Flosser used once daily for a period of no less than 30 days.
This treatment is medically necessary to treat or mitigate the condition described above; it is not for general
health and is not for cosmetic purposes.
_____________________________________________
__________________
Signature of Attending Dentist
Date
_____________________________________________
Printed Name (First & Last)
______________________________________________________________________________
Address
(____) ____- _______
Telephone Number
4822-2529-9462.2

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