Letter of Necessity.  Printable version

This Letter of Medical Necessity serves as a prescription for my patient to participate in an outpatient weight loss and/or nutrition-for-diabetes program.

To be filled out by patient:

Patient name:
Gender:
DOB:
MRN:
Address:
Phone/cell:
Physician name:
Phone:
Fax:

To Be filled out by physician:

Date:
Last 3 weights:
BMI:
Last 3 HgA1c’s:
Year diagnosed with pre, T1, or T2 DM:
Date last diabetes class attended:

Participating in the Holistic Intermittent Fasting program will support improved overall health. My patient is also diagnosed with:

______ CKD stage 1,   2,   3 (circle) (do not refer if GFR <30) ______ Hypercholesteremia  

______ Hyperlipidemia           ______ Hypertension              ______ Fatty liver disease                  

______ Sleep Apnea                ______ Comments _______________________________________________

Do not refer if patient frail/immobile, has various system failures, and/or seeing specialty physicians more than once per year.

Print Physician name: ______________________________________________________________

Physician Signature: _______________________________________________________________

Patient to keep this letter for tax purposes as proof for possible reimbursement from his/her Health Spending Account.