Nancy Lum, RD, LDN 700 Geipe Rd., Ste 203 Catonsville, MD 21228 PHONE: 443-490-1240 EMAIL: nutritiontruth@gmail.com Website: www.Nutrition5.com
Today’s Date:
To Whom It May Concern,
_________________________________ had ______________________ surgery on _________. Patient is required to take the following vitamins post-surgery: 1200-1500mg Calcium Citrate, 2000-3000IU Vitamin D3, 2 – adult chewable or liquid of a complete Multi-Vitamin 30-60mg of Elemental Iron Patient is seeking reimbursement due to medical/surgical condition for vitamins as these vitamins are medically necessary to prevent medical conditions caused by vitamin deficiencies. This patient is currently taking: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
_________________________________________________ _______________ Dietitian Signature
Date
_________________________________________________ _______________ Surgeon’s Signature
1
Medical Necessity – Vitamins GBP rev. 1/11/12 hn| GIBNC
Date