3853 (02/2015)
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,
online at www.wageworks.com.
TO BE FILLED OUT BY PARTICIPANT
Patient Name
Participant Name
Participant Employer
Last 4 digits of Participant ID or Social Security #
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 specic 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 Benets from your Medical Insurance Provider and complete a 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 led.
www.wageworks.com
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