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.
Customer Reviews
Have bought many items for LG Medical since 2012 and never had an issue. Service is always great and the products are excellent quality for a great price. If you have a question and call they are knowledgeable about their products plus the LG web site has many videos and tips. I will continue to buy from LG Medical as I feel the are one of the best in their field. DMD-
A family member ordered from LGMedSupply in the past and had great service, and that is why I felt safe ordering from them. And they didn't let me down. I got exactly what I ordered and it got to me when it was supposed to so that is why I gave them the top rating. -
I injured my hip bowling. I am a 45 year old female and I thought I had to live with this deep aching annoying pain for the rest of my life; it had been ongoing for 3 years. Oh my goodness this Tens unit changed my life in 3 days. -
My husband had a very painful back problem and we ordered a TENS unit from LG. We got it in a couple of days and are delighted with the service from LG and the efficiency of the TENS unit. -
I did not understand fully how to use the Tens Unit. Lucy with customer service was SO patient and walked me through the entire process My feet felt better just after one session! -
I purchased this unit after having a knee replacement. I decided to go with the unit that had EVERYTHING ( the price of the unit was the price of two trips to the doctor, it pays for itself).
