WW-LTR-OF-MED-NEC (Mar 2013)
Letter of Medical Necessity
Your medical care provider must complete a Letter of Medical Necessity for any service or product that falls under the
category of “Maybe Expense” or “Ineligible Expense” per IRC sec 213 (d) (1) if your provider believes the service or
purchase is medically necessary for you or your eligible dependent(s). You may obtain a list of eligible and ineligible
expenses, as well as a Claim Form, on the WageWorks website at www.wageworks.com
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TO BE FILLED OUT BY PARTICIPANT
Patient Name
Participant Name
Participant Employer
Last 4 digits of participant ID or SSN
TO BE FILLED OUT BY LICENSED PRACTITIONER
Medical Condition
Describe recommended treatment (frequency and dosage)
Duration of the treatment
I certify that this service or product is medically necessary to treat the specific medical condition described above and is
not in any way for general health or for cosmetic purposes.
Print Name of Licensed Practitioner Signature of Licensed Practitioner Date
NOTE: In order for the expense referred to on this Letter of Medical Necessity to be reimbursed, you must attach the
detailed receipt or Explanation of Benefits from your Medical Insurance Provider and complete a WageWorks Claim Form
(certain expenses may require additional documentation). Documentation must include the date of service, the
services rendered or product purchased and the person for whom the services were rendered and the amount charged.
These documents are required with each claim filed.
