Phone: (952) 431-9708

Physicians Checklist

1. Complete the LMN (Letter of Medical Necessity)
Page 1 filled out by physician
Must be filled out
Provider  #
Date of Birth needs to be filled out
ICD-10 Needs to be filled in and should be M62.50.
Check box for Length of Need (6 weeks or 12 weeks)
Physician Signature

2. Submit face sheet (demographic page)
3. Submit (History & Physical)
4.Submit Medical Note with this statement
"In my evaluation of this patient I have noted there is a high risk of developing DISUSE ATROPHY. I am prescribing ARP Wave Neuro Therapy involving the use of the patented ARP Wave Device and the necessary electrodes needed to complete 6-weeks of therapy in the patient’s home. This patient has decreased ability and duration of ambulation, which will significantly increase the risk factors associated with DISUSE ATROPHY.

All patient’s sign page 2 of the LMN

Work Comp/Motor Vehicle Accident claims needs Signature in Worker's Comp box

For any Work Comp/MVA claim we will need a Date of Injury

5.       Include a clean copy of the patient's insurance card, if possible (Front & Back)

6.       Submit using this form