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L e t t e r o f M e d i c a l N e c e s s i t y
P l e a s e p r i n t o r t y p e i n f o r m a t i o n b e l o w a n d c o m p l e t e f o r m i n i t s e n t i r e t y
T h e f o l l o w i n g M H C P m e m b e r h a s r e q u e s t e d t o b e s e e n a t F O R M T E X T f o r m e d i c a l s e r v i c e s . T h e y h a v e r e q u e s t e d M N e t t o a u t h o r i z e t r a n s p o r t a t i o n t o t h i s f a c i l i t y ; w h i c h i s F O R M T E X T m i l e s f r o m t h e i r h o m e . M N e t i s r e q u i r e d t o p r o v i d e t r a n s p o r t a t i o n t o t h e c l o s e s t m e d i c a l p r o v i d e r a b l e t o p r o v i d e m e d i c a l s e r v i c e s . P l e a s e p r o v i d e a n e x p l a n a t i o n a s t o w h y m e d i c a l s e r v i c e s c a n n o t b e p r o v i d e d a t a c l o s e r m e d i c a l f a c i l i t y .
P a t i e n t N a m e : F O R M T E X T D O B : F O R M T E X T M A # : F O R M T E X T
1 . D i a g n o s i s f o r w h i c h y o u a r e t r e a t i n g m e m b e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________________________________________________________
2. Have you referred the patient to be seen by a specialist? FORMCHECKBOX Yes FORMCHECKBOX No
Physician/Specialist name _________________________________________________
3. Can the patient receive treatment at a closer medical facility? FORMCHECKBOX Yes FORMCHECKBOX No
If Yes, please list: _______________________________________________________________
If No, complete section 4 below:
4. Please indicate treatment/services, and why they cannot be preformed at medical facility closer to the patients home:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5. Anticipated duration of treatment: ______________________________________________________
X_____________________________________ ________________ _________________________ Provider Signature Date Contact #
_________________________________ ________________ __________________________
Provider Name (printed) Provider License # Facility Name
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Upon completion, please fax this form with cover sheet to:
MNets Care Management Department
Fax: 651-203-1262
1110 Centre Pointe Curve, Suite 220 Mendota Heights, MN 55120 | phone 866.467.1724 | fax 651-203-1262 | www.mtm-inc.net
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