Certificate Of Medical Necessity Template

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CERTIFICATE OF MEDICAL NECESSITY
Under Internal Revenue Service (IRS) rules, some health care services and products are only eligible for reimbursement from your Health
Flexible Spending Account (FSA), Limited FSA and Health Reimbursement Arrangement (HRA) when your practitioner certifies that they are
medically necessary. WageWorks has developed this Certification of Medical Necessity (CMN) to assist you and your health care practitioner in
supplying the information needed in order to process your claim. Your practitioner can also submit a statement on his or her letterhead, as long
as the letter includes all of the information that is included on this form. By submitting this CMN 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. The Role of WageWorks is to ensure that the proper documentation is received in order to approve reimbursements under
your employer’s plan.
THIS FORM WILL BE DENIED, WITHOUT REVIEW, IF IT IS NOT COMPLETED IN ITS ENTIRETY.
THIS FORM WILL NOT BE ACCEPTED IN PLACE OF A DOCTOR’S PRESCRIPTION FOR THE REIMBURSEMENT OF OTC DRUGS AND MEDICINES.
PLAN INFORMATION
EMPLOYER NAME _____________________________________________________________________________ PLAN YEAR _____________________________________
EMPLOYEE INFORMATION
Complete this section for the primary account holder.
FIRST NAME _________________________________________ LAST NAME _________________________________________ SSN _______________________________
1
DAYTIME PHONE _____________________________________ EMAIL
_________________________________________________________________________________
¹ Email: By providing your email address, you agree to receive Employee Benefit Plan correspondence electronically. WageWorks does not share, sell or divulge individual
private information to any third party. All individual private information, including your email address, is used solely to administer your benefit account(s). Please add our email
address, , to your approved senders list to ensure delivery of all correspondence and notifications. You can change/delete your e-mail address by contacting the
WageWorks Customer Service Department or by visiting our website at WageWorks reserves the right to utilize an email address that may be provided to us by
your employer.
THE NEXT TWO SECTIONS SHOULD BE COMPLETED BY YOUR LICENSED PRACTITIONER.
MEDICAL CONDITION INFORMATION
PATIENT FIRST NAME ____________________________________________________ PATIENT LAST NAME __________________________________________________
DIAGNOSIS: __________________________________________________________________________________________________________________________________
RECOMMENDED TREATMENT: ___________________________________________________________________________________________________________________
*Products and procedures must be itemized.
DURATION OF RECOMMENDED TREATMENT: ______________________________________________________________________________________________________
*If the duration of treatment extends beyond the end of the current plan year, a new Certificate of Medical Necessity will be required for the next plan year.
PRACTITIONER CERTIFICATION AND INFORMATION
I certify that the recommended treatment is medically necessary and is not solely for cosmetic purpose or general good health.
PRACTITIONER SIGNATURE ________________________________________________________________
DATE ____________________________
PRACTITIONER NAME _______________________________________________ LICENSE NUMBER AND STATE _______________________________________________
WageWorks •
P.O. Box 4594, Greenwood Village, CO 80155-4594
Customer Service 800-800-0133 Local 303-221-2783
CMN_092811
Fax 303-221-2785

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