Letter of Medical Necessity

Fill this out, print it, and bring it to your clinician. A signed letter can help support an HSA/FSA reimbursement request when Sage is used for qualifying medical care.

Sage does not decide HSA/FSA eligibility and this page is not tax, legal, or medical advice. Reimbursement depends on the user's plan administrator and may require additional documentation.

Letter of Medical Necessity for Sage Care Support Subscription

Medication adherence, appointment reminders, doctor-visit documentation, care binder, cognitive support, and caregiver alerts.

Date

Patient Information

Patient name

Date of birth

Parent, guardian, or caregiver, if applicable

Plan/member ID, optional

Medical Need

Diagnosis or medical condition

Recommended duration

Why Sage is medically necessary for this patient

Recommended Product or Service

Product/service

Billing frequency

Estimated cost

Medically Relevant Functions

Medication list, dose schedule, reminders, and adherence support Doctor appointment capture, calendar support, and reminders Doctor-visit notes, transcription, and follow-up documentation Care Binder for health conditions, doctors, medications, and care details Cognitive support for memory, routine follow-through, and care-plan tasks Caregiver alerts for missed medications, inactivity, emergency needs, or care concerns

Clinician Statement

I am a licensed health care professional treating the patient named above. In my medical judgment, Sage Care Support Subscription is medically necessary for this patient to support management of the condition(s) listed above and to assist with medication adherence, appointment follow-through, doctor-visit documentation, care coordination, cognitive support, and caregiver awareness.

This recommendation is for the duration listed above, after which the patient's need should be reassessed.

Clinician Information

Clinician name

NPI or license number

Practice or organization

Phone

Address

Clinician signature

Signature date

For HSA/FSA claim submission, the patient should keep this signed letter, an itemized Sage receipt, and any plan-required documentation with their tax or benefit records. Sage Companion LLC does not guarantee reimbursement.