Instructions for Client Fill in Sections 1 and 2 before bringing this form to your physician. Your doctor completes Sections 3 through 5, signs, and returns it to you. Once signed, use this letter when submitting HSA/FSA reimbursement requests or out-of-network insurance claims.

Section 1 — Patient Information

Patient Name

Date of Birth

Patient Address

Patient Phone

Section 2 — Referred Program

Program / Studio Name

Coach / Provider

Studio Address

Studio Phone / Email

Studio NPI

Taxonomy Code

Start Date

Section 3 — Physician Recommendation (completed by physician)

To the reviewing clinician or plan administrator:

I am referring the above-named patient to structured exercise and wellness coaching sessions at Say CHEESE and LIFT! Studio under the direction of Coach Evan Johnson. These sessions are medically recommended to support the patient's ongoing treatment plan and address the following condition(s):

Select all applicable diagnoses:

Musculoskeletal disorder / injury rehabilitation Obesity / weight management (BMI ≥ 30) Type 2 diabetes / pre-diabetes / metabolic syndrome Cardiovascular disease / hypertension Anxiety / depression / mood disorder Chronic pain management Osteoporosis / osteopenia / bone density Post-surgical rehabilitation

Other:

Section 4 — Recommended Program (completed by physician)

Frequency

Duration

Session Length

Additional Clinical Notes

Section 5 — Physician Certification & Signature (completed by physician)

Certification Statement I certify that the structured exercise and wellness coaching program described above is medically necessary to support this patient's treatment plan. I have reviewed the patient's health history and believe participation in this program is appropriate and beneficial to their care.

Physician Name (Print)

Physician NPI Number

Practice / Clinic Name

Phone & Address

Physician Signature

Signature ______________________________

Date Signed

Date ___________________________________

Notice: This letter documents a physician's recommendation and does not guarantee HSA/FSA eligibility or insurance reimbursement. The client remains responsible for confirming plan-specific requirements with their HSA/FSA administrator or insurer. Say CHEESE and LIFT! Studio does not bill insurance directly and does not guarantee reimbursement outcomes.