Complete CMT Evaluation - Letter of Medical Necessity

This template may be used to create a letter of medical necessity for Athena’s Complete CMT Evaluation. You may choose to download the blank Word document or use the convenient form template below. If we can be of further assistance, please contact us at (800) 394-4493.

Physician InformationPatient & Insurance InfoDisorder and Test Information

Physician Information

Name:
NPI#:
Address:
Address 2:
City:
State:	Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
Zip:
Phone Number:

Patient Information

Patient Name:
DOB: (MM/DD/YYYY)
Gender:	male female

Insurance Information

Medical Director/Physician Name:
Insurance Company:
Address:
Address 2:
City:
State:	Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
Zip:
Insurance ID Number:
Group ID:

Disorder and Test Information

List Primary Clinical Symptoms:	1. ICD-9: 2. ICD-9: 3. ICD-9: 4. ICD-9: 5. ICD-9: 6. ICD-9: 7. ICD-9: