Fillable Printable FSA Letter of Medical Necessity Form
Fillable Printable FSA Letter of Medical Necessity Form
FSA Letter of Medical Necessity Form
FSA Letter of Medical Necessity
Under Internal Revenue Service (IRS) rules, some health care services and products are only eligible for
reimbursement from your Health Care Flexible Spending Account (HCFSA) when your doctor or other
licensed health care provider certifies that they are medically necessary. Your provider must indicate your (or
your spouse’s or dependent’s) specific diagnosis, the specific treatment needed, and how this treatment will
alleviate your medical condition.
ASI has developed this letter to assist you and your health care provider in providing the information we need
in order to process your claim. Your provider can also submit a statement on his or her letterhead, as long as
the letter includes all of the information on this form.
You only need to submit this submission form, or your provider’s letter containing the same information, with
the first claim you submit for the service or product. ASI will make a notation on your record of the allowable
item(s) and the date on the letter. The letter will be valid for expenses incurred for one year from the date on
the letter. At the end of one year, a new letter will be required.
[Date]
[Employee Name] [SSN/EID]
[Patient Name]
[Diagnosis] [CPT Code]
Dear ASI:
Please describe what the recommended treatment is, how that treatment will alleviate the diagnosis
or symptoms, and the duration of the treatment required.
Sincerely,
[Provider Signature]
[Provider Name]
[Provider License # & State]
[Provider Telephone #]
If you have questions you may visit the ASI website at www.asiflex.com or contact an ASI benefits
counselor at 1-800-659-3035, Monday through Friday, 7 A.M. to 7 P.M. Central Time.
Note: ASI’s role is to ensure that the proper documentation is submitted for reimbursement under
your FSA plan, and not to determine whether the treatment prescribed by your health provider is
medically necessary. ASI will review this letter of medical necessity for completeness only.
