Letter of Medical Necessity
Need a letter from your care team?
Some HSA and FSA plans ask for a Letter of Medical Necessity before they'll reimburse a PICC or midline cover. We've made a simple template to bring to your doctor, nurse practitioner, or infusion nurse.
Download the Letter of Medical Necessity (PDF)How it works
- Download the letter and print it, or email it to your care team.
- Your clinician completes and signs it.
- Keep it with your Nova order confirmation, and submit both if your plan asks.
Your letter is yours to keep. Please don't send it to us, since it includes your health information.
Eligibility and reimbursement depend on your individual plan, so check with your plan administrator if you're unsure. Nova provides this template for convenience and does not determine medical necessity or guarantee reimbursement.