Letters of Medical Necessity & Detailed Written Order Templates

***The following template letters have been drafted to provide background information on Vitaflo products. These letters are intended to be used by the patient’s health care professional (HCP), including dietitians and physicians. These templates can be customized by the HCP for each individual patient. The list of diagnoses contained in these letters is not all-inclusive. It is ultimately and solely the health care professional’s responsibility to determine and document the appropriate diagnosis for the patient’s condition. Please note that Vitaflo does not guarantee that use of these resources, or any of the information contained within them, will result in insurance coverage or reimbursement by any third party payor. Sections of each template letter have been left unprotected so that the HCP may include patient specific information.***

Detailed Written Order Template

Detailed Written Order Template

Letters of Medical Necessity

Single Dose Amino Acids

Betaquik

Carbzero

EAA Supplement

FruitiVits (Ketogenics)

FruitiVits (Inborn Errors of Metabolism)

GA Express15

GA Gel

Glycosade

HCU cooler15

HCU express15

HCU express20

HCU gel

Lipistart

Maternal PKU

MCT Procal

MMA-PA cooler15 (MMA)

MMA-PA cooler15 (PA)

MMA-PA express15

MMA-PA gel

MSUD cooler15

MSUD express15

MSUD express20

MSUD gel

PKU coolers

PKU express15

PKU express20

PKU gel

Renastart

S.O.S

TYR cooler15

TYR express15

TYR express20

TYR gel

UCD trio

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Carbzero, Fruitivits, Keyo, Vitabites, SOS and Single Dose Amino Acids are not eligible for Formula4Success.
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