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Please Note: We will be closed 12/23 to 12/26 and 12/31 to 1/2/2022 to celebrate the holidays with our families. We hope you enjoy time with your loved ones as well!

WEATHER ALERT! UPDATE 4/20: Unfortunately, our business continues to not have power. Our County was hit hard by the snowstorm and several power substations are still not operational. Please email info@adaptivemall.com with any questions or concerns and we will answer you as soon as we are able. We do have a few a staff that work remotely and will do their best to answer questions as they can! Thank you for your continued patience! 

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Sample Letters of Medical Necessity

Sample Letters of Medical Necessity

Below you will find Sample Letters of Medical Necessity for various products. You can click to read the letter in a webpage format as well as download a pdf of the content.

Tip: Contact the beneficiary's insurance company and ask them to provide you with their definitions of medical necessity. Be sure to include all components in your letter while using the samples below as a general guideline.


Sample Letter of Medical Necessity for Special Tomato® CatchUp Chair™

 

Click here to view the letter in a webpage

 

Click here to Download the PDF


Sample Letter of Medical Necessity for Special Tomato® Soft-Touch® Booster Car Seat

 

Click here to view the letter in a webpage

 

Click here to Download the PDF


Sample Letter of Medical Necessity for Special Tomato® MPS Car Seat

Click here to view the letter in a webpage

 

Click here to Download the PDF


Sample Letter of Medical Necessity for Special Tomato® Multi-Positioning Seat (MPS)

 

Click here to view the letter in a webpage

 

Click here to Download the PDF


Sample Letter of Medical Necessity for Special Tomato® Hi-Low Multi-Positioning Seat (MPS)

 

Click here to view the letter in a webpage

 

Click here to Download the PDF


Sample Letter of Medical Necessity for Special Tomato® Soft-Touch Sitter

 

Click here to view the letter in a webpage

 

Click here to Download the PDF