Steponefoods Health Insurance Reimbursement (Page 2 of 2) in pdf

Steponefoods Health Insurance Reimbursement Page 2

LETTER OF MEDICAL NECESSITY

DISEASE SPECIFIC NUTRITION: STEP ONE FOODS PROGRAM

This letter serves as a prescription and letter of medical necessity for the patient referenced below currently

being treated for heart disease, hyperlipidemia, hypertension, or heart failure with or without obesity.

To be filled out by patient:

Patient Name

Sex ________ DOB __________________

Address

Phone ________________

City/State/Zip

SS# __________________

Physician _______________________________Phone ______________________Fax __________________

To be filled out by physician regarding patient listed above:

DATE

HEIGHT

WEIGHT

BMI

BMI Weight Class (check one)

Normal (18.5 ‐ 24.9)

Overweight/Pre‐obese (25.0 ‐ 29.9)

Obese (30.0‐39.9)

Extremely Obese (40.0+)

Physician Order: I refer this patient to be on the Step One Foods Heart Care Nutrition Support program.

Diagnoses (check all that apply)

_____ Congestive Heart Failure

_____ Obesity

_____ Hypercholesterolemia

_____ Morbid Obesity

_____ Sleep Apnea

_____ Coronary Atherosclerosis

_____ Type 2 Diabetes

_____ Hypertriglyceridemia

_____ Impaired Glucose Tolerance

_____Mixed Hyperlipidemia

_____ Hypertension

_____ Other (list):

Physician Comments: ____________________________________________________________________

Physician Signature _______________________________________ Date ______________________________

THANK YOU!

Patients should keep this letter for tax purposes for proof necessary for reimbusement under a Flexible

Spending Account, Health Reimbursement Account, or Health Insurance Coverage Plan.

Steponefoods Health Insurance Reimbursement Page 2