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Simply Fax Patient Forms to LGMedSuppy at (888)633-7360. (Includes Medical Doctors, Chiropractors, Dentists, Podiatrists, Nurse Practitioners, Physicians Assistants, Ph.D., Physical Therapists, Doctor of Acupuncture or Doctor of Osteopathy)

Letter of Necessity Form

LETTER OF MEDICAL NECESSITY FORM:



First Name: ________________________________________

Last Name: ________________________________________

Date of Birth: ______________

Clinic Name: _______________________________________

Clinic Phone Number: _______________________________

Patient Information:

____________________________________________________

____________________________________________________

____________________________________________________



Electrical Stimulation Units (check the unit being prescribed):

____ TENS Unit

____ TENS/EMS Combo Unit

____ Interferential Unit

____ Galvanic Unit

____ Microcurrent Unit

____ Cervical Traction

____ Lumbar Traction



Medical Necessity (check treatment goal):

____ Relax muscle spasms

____ Pain Control

____ Re-educate muscles

____ Retard disuse atrophy/muscle weakness



Length of Use: _______________________________________



Physician Signature x________________________________ (Includes Medical Doctors, Chiropractors, Dentists, Podiatrists, Nurse Practitioners, Physicians Assistants, Ph.D., Physical Therapists, Doctor of Acupuncture or Doctor of Osteopathy)



Phone Number: _______________________________________

Fax Number: _________________________________________

Date ________________________________________________

I the above signed, confirm the order for the above-named patient. I also certify that the prescribed treatment is medically reasonable and necessary in reference to accepted standards of medical practice within the community for treatment of this patients condition.

Please fax 24/7 to (888) 633-7360.

Letter of Necessity Form
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