MEDICAL NECESSITY

DATE:

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FACILITY:

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ADDRESS:

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ADDRESS2:

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CITY, STATE ZIP:

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RE:

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DOI:

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CLAIM:

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To Whom It May Concern:


PATIENT:

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has been diagnosed as having an (extension/flexion) problem contributing to their (carpal tunnel) pathology. This condition is primarily due to the lack of myoligamentous strength of the (carpi) structure and causes instability and biomechanical stress and strain. I have prescribed a custom-fit, strengthening Orthotic, that is specifically designed to improve this condition: "FLEXTEND" Rehabilitative Orthotic Gloves.

If you should require any further information, please do not hesitate to contact this office at:

PHONE:

FAX:

Sincerely,