Letter of Medical Necessity

Please complete the areas marked in red below if you plan to pay for services using a Health Savings Plan (HSA) or a Medical Savings Plan (MSA). Health insurance organizations require documentation of medical necessity when using HSA and MSA medical plans for mental health coaching services. Please have the referring provider complete the Clinical Information section and sign the Referring Doctor Signature for HSA and MSA payments. Email form to stephanie@selflovecoach4.com. All information is strictly confidential.

Demographic Information

Full Name *

Date of Birth *

Phone Number *

Email Address *

Home Address *

Referring Provider

Complete the following information.

Provider Name

Provider Phone

Provider Fax

Clinical Information

Primary Diagnosis / ICD-10 Code *

Secondary Diagnosis (optional)

Treatment / Service Requested *

Clinical Justification *

Accuracy of Information

I certify that all information provided in this Letter of Medical Necessity is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may result in denial of coverage or other consequences.

I have read and acknowledge the above.

Release of Information

I authorize SCJ Mental Health Coaching and any treating providers to release relevant medical and clinical information to my insurance company or other payers as necessary to process this request for medical necessity.

I have read and acknowledge the above.

No Guarantee of Coverage

I understand that submission of this Letter of Medical Necessity does not guarantee insurance approval or coverage. Final determination of benefits is made solely by my insurance provider.

I have read and acknowledge the above.

Digital Signature

Type your full name as your digital signature *

By typing your name above, you agree this constitutes your legal digital signature.

Date *

Referring Doctor Signature Section

To be completed by the referring physician or provider.

Referring Doctor — Type full name as digital signature

By typing their name above, the referring doctor confirms this constitutes their legal digital signature.

Date