Template for a Letter of Medical Necessity and Statement Form: The following content can be
cut and pasted onto your practice's letterhead and used as a Letter of Medical Necessity. The
Statement of Medical Necessity Form is attached for your use at your discretion.
[Medical Director]
[Health Plan]
[Patient Name]
[Date of Birth]
[Insurance ID number]
Dear [Insurance Provider]:
I am writing to request [insert product name] for my patient [name of patient] who I have diagnosed
with Duchenne muscular dystrophy (DMD).
I’ve determined that this patient meets the indication for the product and therefore, this therapy is
medically necessary.
In my clinical opinion, [insert patient name] should receive this therapy for the following reasons:
[List reasons]
Please let me know if you require additional information from my records.
Yours truly,
The following are some of the materials and information that may be requested by Payers in
connection with the Statement of Medical Necessity Form:
Chart notes
Genetic tests
Copy of the patient’s insurance cards
FDA Approval Letter
Prescribing information
Recent medical articles
Letters from other specialists treating the patient such as cardiologists, pulmonologists and physical
and occupational therapists
Patient's psychological factors that are relevant to your chosen treatment
Information to educate Medical Director or Pharmacy Director who is not familiar with the disease
or treatment
Statement of Medical Necessity Form
Site Name: NPI #:
Address: City: State: ZIP:
Site Contact: Fax:Phone: Email:
Site of Care Information
Hospital Clinic Homecare Other
Patient Information
First Name: Last Name: Middle Initial:
Address: City: State: ZIP:
Date of Birth:
Primary Contact:
Primary Phone: OK to leave messages? Yes NoSecondary Phone:
Height (in): Weight (lbs):Gender: Male Female
Relationship to Patient:
Insurance Information
Primary: ID #: Group #: Phone:
Policy Holder:
Policy Holder: Relationship to Patient:
ID #:
Group #: Phone:
First Name: Last Name: State License #:
Address: City: State: ZIP:
Office Contact: Fax:Phone: Email:
Physician Information and Authorization
Physician Signature Date
Method of Diagnosis:
Date Diagnosed:
ICD 10-CM:G71.0
Diagnosis and Treatment Rationale
click to sign
click to edit