Get Letter Of Medical Necessity For Pool

FSA Letter of Medical Necessity Under Internal Revenue Service IRS rules some health care services and products are only eligible for reimbursement from your Health Care Flexible Spending Account HCFSA when your doctor or other licensed health care provider certifies that they are medically necessary. Your provider must indicate your or your spouse s or dependent s specific diagnosis the specific treatment needed and how this treatment will alleviate your medical condition* ASI has developed this letter to assist you and your health care provider in providing the information we need in order to process your claim* Your provider can also submit a statement on his or her letterhead as long as the letter includes all of the information on this form* You only need to submit this submission form or your provider s letter containing the same information with the first claim you submit for the service or product. ASI will make a notation on your record of the allowable item s and the date on the letter. The letter will be valid for expenses incurred for one year from the date on the letter. At the end of one year a new letter will be required* Date Employee Name SSN/EID Patient Name Diagnosis CPT Code Dear ASI Please describe what the recommended treatment is how that treatment will alleviate the diagnosis or symptoms and the duration of the treatment required* Sincerely Provider Signature Provider Name Provider License State Provider Telephone If you have questions you may visit the ASI website at www. asiflex. com or contact an ASI benefits counselor at 1-800-659-3035 Monday through Friday 7 A. M. to 7 P. M. Central Time. Note ASI s role is to ensure that the proper documentation is submitted for reimbursement under your FSA plan and not to determine whether the treatment prescribed by your health provider is medically necessary. Your provider must indicate your or your spouse s or dependent s specific diagnosis the specific treatment needed and how this treatment will alleviate your medical condition* ASI has developed this letter to assist you and your health care provider in providing the information we need in order to process your claim* Your provider can also submit a statement on his or her letterhead as long as the letter includes all of the information on this form* You only need to submit this submission form or your provider s letter containing the same information with the first claim you submit for the service or product. ASI will make a notation on your record of the allowable item s and the date on the letter. The letter will be valid for expenses incurred for one year from the date on the letter. ASI will make a notation on your record of the allowable item s and the date on the letter. The letter will be valid for expenses incurred for one year from the date on the letter. At the end of one year a new letter will be required* Date Employee Name SSN/EID Patient Name Diagnosis CPT Code Dear ASI Please describe what the recommended treatment is how that treatment will alleviate the diagnosis or symptoms and the duration of the treatment required* Sincerely Provider Signature Provider Name Provider License State Provider Telephone If you have questions you may visit the ASI website at www. .