This template is provided as a convenience. Your provider is responsible for its clinical accuracy. Smash Meals does not determine HSA/FSA eligibility.
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Date: __________________________
To Whom It May Concern:
I am writing to document the medical necessity of a specialized diet for the patient identified below. This letter is intended to substantiate the use of Health Savings Account (HSA), Flexible Spending Account (FSA), or Health Reimbursement Arrangement (HRA) funds for qualifying food expenses under IRS §213(d).
Patient name
__________________________
Date of birth
__________________________
Diagnosis
__________________________
__________________________
ICD-10 code(s)
__________________________
Prescribed dietary requirement
__________________________
__________________________
__________________________
Medical justification (why this diet alleviates or treats the condition)
__________________________
__________________________
__________________________
__________________________
Expected duration of medical necessity
__________________________
Provider name
__________________________
Credentials (MD, DO, RD, etc.)
__________________________
NPI number
__________________________
Practice / clinic
__________________________
Phone
__________________________
Provider signature
__________________________
Date signed
__________________________