Insurance Forms

Letters of Medical Necessity

You may be requested to show a letter of medical necessity to your insurance in order to gain coverage of our products. You can get this from your doctor. To accelerate the process, you can show this sample letter of necessity to your doctor specific to the product you need.

Liquid Hope
(ADULT FORMULA)
Sample
letter
Liquid Hope Peptide
ADULT FORMULA
Sample
letter
Liquid Hope Peptide High Protein
ADULT FORMULA
Sample
letter
Nourish
PEDIATRIC FORMULA
Sample
letter
Nourish Peptide
PEDIATRIC FORMULA
Sample
letter
Nourish Peptide Berry Medley
PEDIATRIC FORMULA
Sample
letter
Keto
Ketogenic Formula
Sample
letter

Referral Form

You may find the following referral form helpful in working through the insurance process for all insurances: private, Medicaid and Medicare. Please print the form, and have your physician complete the documents that are required.

This is not a prescription.
Referral Form
Sample
letter

We Can Help

At Functional Formularies we have patient advocates available to help assist you in gaining insurance
coverage for our products. Please fill out the form or call us at 937-433-4673
and we will set up an appointment for you with a patient advocate.
We Can Help
Do you have a current home health company?
Do you have health insurance?
Have you received a denial from your insurance?

HCPCS Codes

Liquid Hope
HCPCS Code: B4149
Nourish
HCPCS Code: B4149
Liquid Hope
Peptide
HCPCS Code: B4153
Nourish
Peptide
HCPCS Code: B4161
Keto
Peptide
HCPCS Code: B4161 & B4153

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