Fillable Flexible-Spending-Letter-of-Medical-Need Letter of Medical Necessity Form

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Flexible-Spending-Letter-of-Medical-Need Letter of Medical Necessity Form

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11/07/16 Page 1 of 1
Statement on the Collection and Use of Social Security Numbers
Human Resources
In accordance with the requirements of Florida law (Section 119.071, Florida Statutes), the University of West Florida
collects social security numbers only if specifically authorized or required by law or if imperative for the performance of
the University’s duties and responsibilities. The University may collect social security numbers for some or all of the
following purposes: identity tracking and management; billing and payments; credit worthiness; data collection;
reconciliation and tracking; benefit processing; tax and scholarship reporting; financial aid processing; student health
services, and reporting to authorized state and federal government agencies. Federal and state laws require us to protect
social security numbers from disclosure to unauthorized parties. Students and employees are assigned UWF
identification numbers to assist in tracking and protecting their personal information.
UWF Forms
Form Purpose
Purpose for SSN#
Statutory Authority
Mandated,
Authorized or
Business Imperative
FRS Certification Form
Eligibility to be employed
Applicant
Identification
Section 119.071(5)(a)6.g,
F.S.
Mandated
Level II Background
Screening Request Form
Eligibility to be employed in
a position of special trust
Applicant/employee
identification
Section 119.071(4)(a)2.b.,
F. S.
Mandated
Verification of Employment
Authorization Release
Employment verification
Employee
identification
Section
119.071(5)(a)(2)(a)(ll), F.S.
Business Imperative
Third Party Non-UWF
Forms
Purpose
Purpose of SSN#
Statutory Authority
Mandated,
Authorized or
Business Imperative
Form I-9, Employment
Eligibility Verification (US
Department of Homeland
Security)
Verify each new employee
(both citizen and noncitizen)
hired after Nov 6, 1986, is
authorized to work in the
United States.
Citizen and
noncitizen
identification
U.S. Dept. of Homeland
Security, U.S. Citizenship
and Immigration Services;
Immigration Reform and
Control Act of 1986, Pub. L.
99-603(8 USC 1324a)
Mandated
Form W-4, Employee’s
Withholding Allowance
Certificate
Tax reporting
For employee
identification
I.R.C. Section 6109
Mandated
Florida retirement
contribution reports and
forms (Florida Department of
Revenue)
Administration of pension
benefits
For employee
identification
Section 119.071(6)(g), F.S.
Business Imperative
Worker’s Compensation
Amerisys forms on behalf of
Risk Management, STARS
reports of lost wages and
First Report of Injury
For report and
documentation of work-
related injury and follow up
For employee
identification
Section 440.185(2)(b), F.S.
Mandated
I.R.C. Section 403b,457b
contribution reports (Internal
Revenue Service)
Employee enrollment and
claims
For employee
identification
I.R.C. Section 6109
Mandated
State of Florida New Hire
Report (Department of
Revenue)
Administration of various
programs: child support
enforcement, Medicaid,
unemployment
compensation, Food Stamp,
aid to disabled, etc.
New hire
identification
Section 409.2576, F.S.
Mandated
State sponsored insurance
enrollment forms and reports
(group health, life, and
dental coverage) (limited to
dependents)
Administration of health
benefits
Dependent
identification
Section 119.071(6)(f), F.S.
Business Imperative
Agency for Workforce
Innovation Unemployment
Compensation forms
Verification of benefits
eligibility
Employee
identification and
verification with
Social Security
Administration
Section 443.091(1)(g), F.S.
Mandated
FICA Alternative Plan Forms
(OPS Retirement)
Selection of 401(a)
Investment options
and Beneficiaries
Reporting
(OBRA 90) IRC
3121(b)(7)(F).
Business Imperative
Letter of Medical Necessity Form
COMPANY INFORMATION
State of Florida
PARTICIPANT INFORMATION (PLEASE PRINT)
Last Name Primary Phone ( ) -
First Name
Secondary
Phone
( ) -
SSN
(or People First ID)
Date of Birth
(mm/dd/yyyy)
/ /
If the letter of medical necessity is required for claims for your spouse or eligible dependent, please provide the following information:
PATIENT NAME RELATIONSHIP TO EMPLOYEE DATE OF BIRTH
/ /
MEDICAL NECESSITY (TO BE COMPLETED BY YOUR HEALTH CARE PROVIDER)
DIAGNOSIS:
CPT CODE:
RECOMMENDED TREATMENT:
EXPLAIN HOW THIS TREATMENT WILL ALLEVIATE THE DIAGNOSIS OR SYMPTOMS OF THE MEDICAL CONDITION:
DATE RANGE OF TREATMENT
From / / through / /
HEALTH CARE PROVIDER INFORMATION AND CERTIFICATION
Provider Name
Provider Phone License # State
By signing below, I certify that this service or product is medically necessary to treat the specific medical condition described above and is not for
general good health or cosmetic purposes.
Licensed Health Care Provider’s Signature: Date
/ /
PARTICIPANT CERTIFICATION
By signing below, I certify that the previous Medical Necessity and Provider Information and Certification sections were completed by the above treating
health care provider. The expense I am claiming is not for general good health or cosmetic purposes. The expense is due to the direct result of the
medical condition as described above and would not have been incurred but to treat the medical condition as recommended by the health care provider. I
also understand that this letter of medical necessity does not guarantee that the expense will be reimbursed under my plan.
Participant Signature (required)
Date
/ /
SEND THIS FORM TO CH
ARD SNYDER
Send the completed form with the signature
Fax: 888.245.8452
(Please DO NOT include a fax cover page.)
of the health care provider and participant
to Chard Snyder using one of the following:
Mail:
3510 I
r
win Simpson Road, Mason, OH 45040
SOF Medical Necessity Form v12.15
Letter of Medical Necessity Instructions
Under Internal Revenue Service rules, some health care services and products are only eligible for
reimbursement from your health care FSA when your licensed health care provider (provider) certifies that they
are medically necessary. The expense also would not have been incurred but for the direct result of treating the
specific diagnosed medical condition. Your provider must indicate your (or your spouse’s or dependent’s)
specific diagnosis, the specific treatment needed, the length of treatment, and how this treatment will
alleviate your medical condition.
Chard Snyder has developed this form to assist you and your 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. (This form is not used for reimbursement of
over-the-counter medications. Those items require a doctor’s prescription.)
For fast and accurate processing of your reimbursement request, please make sure to include this letter of
medical necessity form or your provider’s letter and itemized receipts or other documentation. If you are
claiming membership to a health club, you must not already be a member of a health club and will need to
submit documentation showing the membership was obtained after your provider’s recommendation. The
reimbursement request claim form can be found on the Chard Snyder website. Please be sure to print the
requested information clearly on all documentation submitted.
Please note: If your treatment extends beyond the time period listed by the provider, you will need to submit a
new letter of medical necessity form upon expiration of the initial treatment dates. The maximum time period
provided on the form cannot exceed one year from the date of the provider’s signature. If treatment extends
beyond one year, a new form will be required at the end of each one-year period.
Fax or mail this form and supporting documentation directly to Chard Snyder:
Fax: 888.245.8452 (Please DO NOT include a fax cover page.)
Mail: 3510 Irwin Simpson Road, Mason, OH 45040
If you have questions please contact us:
Call Customer Service: 855.824.9284
Visit our Website: PeopleFirst.MyFlorida.com
Email your questions: FloridaAskPenny@chard-snyder.com For security reasons, please do
not send claims or personal
information through email
Submission of this form is not a guarantee that the expense will be reimbursed.
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Flexible-Spending-Letter-of-Medical-Need Letter of Medical Necessity Form

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Completed 11 February 2020

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