Letter of Medical Necessity

Note: No information entered on this form will be stored or collected in any way.

Step 1: Enter Basic Information:

Patient Data
Name^*
Date of Birth
Social Security Number
HMO ID Number^*
HMO^*
^* Indicates Required Fields.

Prescription

What are you prescribing that needs authorization?^*

Tip: For drugs, be sure to include dose, frequency of administration, and anticipated duration of therapy.

What is the diagnosis for which this prescription is being written?^*

Which of the following medical necessity criteria apply to this prescription?^*

Check all that apply.

	The service or benefit will, or is reasonably expected to, prevent the onset of an illness, condition, or disability.
	The service or benefit will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, injury, or disability.
	The service or benefit will assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities that are appropriate for individuals of the same age.

^* Indicates Required Fields.

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