Examples # 1 Doctor's Letter of Medical Necessity

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Example # 1 Doctor's letter of medical necessity.


Your Dr.'s name, title and Medical license number.

Your Dr.'s street address, office building, room or suite number.

Your Dr.'s City, state and zip code

Your Dr.'s telephone and FAX numbers

Your name.

To Whom It May Concern:

The above named patient has a history of type____1____2 diabetes mellitus and
she/he has had significant hypoglycemia without adequate early warnings,____allergy,____glucose control,_____other________________________________________________problems when she/he uses____synthetic human or other synthetic insulin or ____porcine insulin.  Therefore, the use of the insulins still available and affordably priced in the US is contraindicated in this patient.  The patient manifests the daily need for at least____units of insulin per day and requires at least____1,000 Unit/10cc bottles of insulin every six months.  The patient requires bovine insulin.

Projecting a patient's precise insulin needs is not possible.  At this time, patient would need to use approximately____ bottles of natural Neutral (R) every
six months, and____bottles of natural Isophane (N) every six months, and____bottles of natural Lente (L) every six months, and____bottles of Protamine Zinc (nearest comparable for UL or PZI) every six months.  If she/he does not use the specified medications, the risk of significant and potentially life-threatening problems is markedly increased and other complications can occur.

If there are any question, please do not hesitate to contact this office.


Your Dr.'s signiture and title.
*Just fill in the blanks with the needed information as it pertains to you.
*Copy and paste into word and edit where you need to add or delete anything.
*Anything in red needs to be eliminated or changed to fit your need.
*Note:  You can import for less than six months, but the shipping charge remains the same no matter how many bottles you order.  The shipping charge is about $58.
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