Letter of Medical Necessity

Many of our patients have special needs that require deep sedation or general anesthesia to receive dental care. Some insurance companies may consider reimbursement for sedation services for children under the age of five, a person severely disabled or a person with a medical, mental or behavioral condition.

Claims submitted for reimbursement require a letter of medical diagnosis and necessity from your physician. This letter must be on the physicians’ company letterhead with the physicians’ signature.

Please complete this PRIOR to your first anesthesia visit with us. You may bring the letter with you, fax it to (314) 862-4504, or email it to [email protected]

*Below is an example of what your physician must include in the letter.

EXAMPLE: (To be printed on Physicians’ Company Letterhead)

____________
Date

____________________ has been diagnosed with ______________________.
Patients Name                                                                           Medical Condition

____________________ will require sedation services as it is medically
Patients Name

necessary for dental care to be completed.

______________________________
Physicians’ Signature