Instructions: 

1. Fill in all the relevant sections with accurate information. 

2. Provide detailed medical justification for the necessity of the treatment or equipment. 

3. Once completed, review the form for accuracy. 

4. Sign and date the form. 

5. Submit the form to the appropriate insurance company or entity. 

Remember, this is a generic template and may need to be adjusted based on specific requirements or formats preferred by different insurance companies or medical facilities.