The above named provider has recommended a specific course of therapy, method of treatment or a means
diagnosing and/or treating a medical condition for the patient named above. This decision is a medical decision
that is made by the provider in consultation with the company medical director, based upon the findings of an examination and/or diagnostic testing. The provider believes this recommendation is in the patient’s best interest.
The specific recommendation(s) being made include the following (please note all applicable details):