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Letter of Medical Necessity Prescription Form for Heathcare Providers

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 MEDICAL NECESSITY PRESCRIPTION:

First Name: ________________________________________

Last Name: ________________________________________

Date of Birth: ______________

Social Security Number: _____________________

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

ICD-9 Code: ________________________________________

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 Medical Necessity Prescription Form for Heathcare Providers