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STATEMENT OF MEDICAL NECESSITY (SMN) Please write legibly and complete all required fields (*) to prevent delays. Phone: (888) 754-7651 Fax: (800) 305-1830 Services Requested * (check all that apply)

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What is statement of medical necessity?

A statement of medical necessity is a document that outlines the medical reasons for why a particular treatment or service is needed for a patient.

Who is required to file statement of medical necessity?

The healthcare provider or medical professional who is requesting a specific treatment or service for a patient is typically responsible for filing the statement of medical necessity.

How to fill out statement of medical necessity?

To fill out a statement of medical necessity, the healthcare provider must provide detailed and specific information about the patient's medical condition, the proposed treatment or service, and the supporting evidence or medical rationale for why it is necessary.

What is the purpose of statement of medical necessity?

The purpose of a statement of medical necessity is to justify and explain why a particular treatment or service is medically necessary for a patient, especially for insurance or reimbursement purposes.

What information must be reported on statement of medical necessity?

The statement of medical necessity should include the patient's demographics, medical diagnosis, treatment plan or service requested, supporting medical evidence or rationale, and the healthcare provider's contact information and credentials.

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