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.