Examples # 1 Doctor's Letter of Medical Necessity

Email me if you have any questions.
Example # 1 Doctor's letter of medical necessity.
___________________________________________________________________________________________





Date:



________________________________________
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

RE:_____________________________________
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.

Sincerely,



________________________________________________
Your Dr.'s signiture and title.
Instructions
*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.
INDEX
USA Pages
Home Page
Main Index
How to Import Beef Insulin-USA
Your Statement Letter to the FDA
Import Permit Application-USA
Additional Related Links
CP Pharmaceuticals Insulin Order Form
Pork Insulin Availability-USA
News-USA
Hosting by WebRing.