F2010-002 (10/20) | HRA/FSA Statement of Medical Necessity Form | Fax (863) 577-4460
HRA/FSA Statement of Medical
Necessity Form
Return this completed form to:
MidAmerica Administrative & Retirement Solutions
PO Box 24927, Lakeland, FL 33802
Ph: (855) 329-0095
Participant Name Social Security Number
Employer Name
Email Address
Patient Name (Must be participant, spouse, or an eligible dependent) Date of Birth (MM/DD/YYYY)
Name Office Phone
Office Name Health Care Provider’s Specialty
Treatment Period (*include start and stop date) Diagnosis Code
Describe Required Treatment
*If no stop date is provided, this form will be valid for one year.
Signature of Licensed Health Care Provider
I hereby certify that the treatment administered for the above patient is required and medically necessary, and
not for general health or cosmetic purposes.
Signature: _______________________________________________ Date: ___________________
Participant Authorization
I am substantiating my request for payment from my Health Reimbursement Arrangement or my Flexible
Spending Account for the expenses listed above. I certify that all expenses for which reimbursement or payment
is claimed were incurred either by me, my spouse, or my eligible dependent(s). To the best of my knowledge,
my statements on this form are true and complete. I take full responsibility for the accuracy of all information I
have provided.
Signature: _______________________________________________ Date: ___________________
To properly verify medical expenses
that you have submitted for reimbursement, we must obtain authorization from the licensed health
care provider administering your treatment.
TO BE COMPLETED BY PARTICIPANT
TO BE COMPLETED BY LICENSED HEALTH CARE PROVIDER
