For Nerva members in the United States
Print this template (or save it as a PDF) and take it to the licensed provider who manages your condition. They complete the blanks and sign it, and you submit it to your HSA/FSA administrator with your Nerva receipt, or keep both on file.
Your plan administrator makes the final eligibility call. The clinical details are for your provider to complete. The letter is theirs, under their signature.
Re: Letter of medical necessity for (DOB )
To whom it may concern,
I am the treating provider for the above patient, who is under my care for (diagnosis code, if applicable: ).
To manage this diagnosed condition, I have recommended Nerva, a six-week health program for managing irritable bowel syndrome and other GI conditions, developed by Mindset Health and delivered as an annual subscription. In my clinical judgment this program is medically necessary for the management of the patient's diagnosed condition as part of their care plan, and is not for general health or wellbeing.
Recommended duration of use: (the program subscription provides 12 months of access).
Please contact my office if further information is required to establish eligibility.
Sincerely,
Signature:
Name & credentials:
NPI (if applicable):
Practice & phone: