Insurance Statement of Medical Necessity

Matia Mobility has partnered with Tamm Net to help streamline the process of securing insurance coverage, making it easier, faster, and more efficient for you to get the approvals you need. Please fill out the form below as completely as possible and one of our insurance experts will be in touch with you.

Matia Mobility Letter of Medical Necessity

MedicalNecessityForm

Provider Information

Prescribing Clinician

Name of Practice

Office Address

Address Line 1

Address Line 2

City

State

Zip Code

Clinical Contact Name

Contact Email

Office Phone

Office Fax

Provider Tax ID

Provider NPI

Patient Information

Patient Name

Date of Birth

MRN

Device Information

Item: E1399 – Tek RMD M1

Accessories: E0844 – Power Wheelchair Group 4

E2300 – Power Seat Elevation System

E0638 – Standing Frame

E2301 – Power Standing System

K0108 – Standing Control System Remote

E0953 – Lateral Knee Supports

E2363 – Group 24 Batteries

E6021 – Seat Sling Adjustable

K0844 – Outdoor Wheel Conversion

Letter of Medical Necessity

Please review and edit the patient specific information below. Please make any edits you feel are warranted for the patient. When you are done editing, please press the SUBMIT FORM button at the bottom. Thank you.

Specific Patient’s Need