{
    "section": "kct-officeform",
    "templateSet": "Letter of Medical Necessity",
    "templates": [
        {
            "text": "Recipient",
            "template": "Letter of Medical Necessity{children},",
            "children": [
                {
                    "text": "to whom it may concern",
                    "template": "To whom it may concern"
                },
                {
                    "text": "name and title (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Patient's Name (list name)",
            "template": "I am contacting you regarding my patient {text}, who is currently under my medical\n                        care.\n                    ",
            "type": "alpha"
        },
        {
            "text": "Regarding the need for",
            "template": "This letter is regarding the need for {text}.",
            "type": "alpha"
        },
        {
            "text": "(He or She",
            "template": "{children}",
            "children": [
                {
                    "text": "He",
                    "template": "He"
                },
                {
                    "text": "She",
                    "template": "She"
                }
            ]
        },
        {
            "text": "Diagnosis)",
            "template": "has been diagnosed with {text}.",
            "type": "alpha"
        },
        {
            "text": "Onset",
            "template": "The onset of this condition(s) began on {text}.",
            "type": "date"
        },
        {
            "text": "Medical Hx specific to visit",
            "template": "Medical history for this patient includes {children}.",
            "children": [
                {
                    "text": "arthritis",
                    "template": "arthritis"
                },
                {
                    "text": "asthma",
                    "template": "asthma"
                },
                {
                    "text": "cardiovascular disease",
                    "template": "cardiovascular disease"
                },
                {
                    "text": "COPD",
                    "template": "COPD"
                },
                {
                    "text": "diabetes",
                    "template": "diabetes"
                },
                {
                    "text": "GE reflux",
                    "template": "GE reflux"
                },
                {
                    "text": "gout",
                    "template": "gout"
                },
                {
                    "text": "hypercholesterolemia",
                    "template": "hypercholesterolemia"
                },
                {
                    "text": "immunosuppression",
                    "template": "immunosuppression"
                },
                {
                    "text": "liver disease",
                    "template": "liver disease"
                },
                {
                    "text": "osteoarthritis\/DJD",
                    "template": "osteoarthritis\/DJD"
                },
                {
                    "text": "osteoporosis",
                    "template": "osteoporosis"
                },
                {
                    "text": "malignancy",
                    "template": "malignancy"
                },
                {
                    "text": "myocardial infarction",
                    "template": "myocardial infarction"
                },
                {
                    "text": "neuromuscular disease",
                    "template": "Hx neuromuscular disease"
                },
                {
                    "text": "peripheral vascular disease",
                    "template": "peripheral vascular disease"
                },
                {
                    "text": "renal disease",
                    "template": "renal disease"
                },
                {
                    "text": "stroke",
                    "template": "stroke"
                },
                {
                    "text": "thyroid disease",
                    "template": "thyroid disease"
                },
                {
                    "text": "obesity",
                    "template": "obesity"
                },
                {
                    "text": "Other medical Hx (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Alternative treatments\/medications (describe)",
            "template": "Alternative treatments and medications tried include {text}.",
            "type": "alpha"
        },
        {
            "text": "Indications\/Expectations",
            "template": "Indications and expected benefits with the above treatment are {children}.",
            "children": [
                {
                    "text": "relaxation of muscle spasm",
                    "template": "relaxation of muscle spasm"
                },
                {
                    "text": "significantly increase mobility",
                    "template": "to increase mobility significantly"
                },
                {
                    "text": "muscle re-education",
                    "template": "aid in muscle re-education"
                },
                {
                    "text": "increase local blood circulation",
                    "template": "increase local blood circulation"
                },
                {
                    "text": "improve clinical picture",
                    "template": "improve the clinical picture"
                },
                {
                    "text": "significantly reduce pain",
                    "template": "significantly reduce pain"
                },
                {
                    "text": "relief and management of chronic pain",
                    "template": "relief and management of chronic pain"
                },
                {
                    "text": "avoidance of drug dependency",
                    "template": "avoidance of drug dependency"
                },
                {
                    "text": "significantly reduce medication",
                    "template": "significantly reduce medication, as to frequency and amount needed"
                },
                {
                    "text": "other indications\/expectations (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Prognosis",
            "template": "At this time, the patients prognosis is {children}.",
            "children": [
                {
                    "text": "fair",
                    "template": "fair"
                },
                {
                    "text": "good",
                    "template": "good"
                },
                {
                    "text": "excellent",
                    "template": "excellent"
                }
            ]
        },
        {
            "text": "(Time of Treatment",
            "template": "The prescribed time of treatment is {children},",
            "children": [
                {
                    "text": "Duration (mins)",
                    "template": "{text} minutes",
                    "type": "number"
                },
                {
                    "text": "Duration (hours)",
                    "template": "{text} hours",
                    "type": "number"
                },
                {
                    "text": "other time of treatment (describe)",
                    "template": "{text}",
                    "type": "alpha"
                }
            ]
        },
        {
            "text": "Frequency of use)",
            "template": "{children}.",
            "children": [
                {
                    "text": "Duration (time per day)",
                    "template": "{text} times per day",
                    "type": "number"
                },
                {
                    "text": "Duration (time per week)",
                    "template": "{text} times per week",
                    "type": "number"
                }
            ]
        },
        {
            "text": "Duration of Use",
            "template": "Duration of need for use or treatment is {children}.",
            "children": [
                {
                    "text": "days",
                    "template": "days",
                    "children": [
                        {
                            "text": "1",
                            "template": "1"
                        },
                        {
                            "text": "2",
                            "template": "2"
                        },
                        {
                            "text": "3",
                            "template": "3"
                        },
                        {
                            "text": "4",
                            "template": "4"
                        },
                        {
                            "text": "5",
                            "template": "5"
                        },
                        {
                            "text": "6",
                            "template": "6"
                        },
                        {
                            "text": "7",
                            "template": "7"
                        }
                    ]
                },
                {
                    "text": "weeks",
                    "template": "weeks",
                    "children": [
                        {
                            "text": "1",
                            "template": "1"
                        },
                        {
                            "text": "2",
                            "template": "2"
                        },
                        {
                            "text": "3",
                            "template": "3"
                        },
                        {
                            "text": "4",
                            "template": "4"
                        }
                    ]
                },
                {
                    "text": "months",
                    "template": "months",
                    "children": [
                        {
                            "text": "1",
                            "template": "1"
                        },
                        {
                            "text": "2",
                            "template": "2"
                        },
                        {
                            "text": "3",
                            "template": "3"
                        },
                        {
                            "text": "4",
                            "template": "4"
                        },
                        {
                            "text": "5",
                            "template": "5"
                        },
                        {
                            "text": "6",
                            "template": "6"
                        },
                        {
                            "text": "7",
                            "template": "7"
                        },
                        {
                            "text": "8",
                            "template": "8"
                        },
                        {
                            "text": "9",
                            "template": "9"
                        },
                        {
                            "text": "10",
                            "template": "10"
                        },
                        {
                            "text": "11",
                            "template": "11"
                        },
                        {
                            "text": "12",
                            "template": "12"
                        }
                    ]
                },
                {
                    "text": "years (specify)",
                    "template": "{text} years",
                    "type": "number"
                },
                {
                    "text": "other length of use (describe)",
                    "template": "{text}",
                    "type": "number"
                }
            ]
        },
        {
            "text": "Statement of Medical Necessity",
            "template": "Utilizing accepted medical practice standards, the above-prescribed {children} is essential in the\n                        continuous treatment of this patient.\n                    ",
            "children": [
                {
                    "text": "DME",
                    "template": "durable medical equipment"
                },
                {
                    "text": "treatment",
                    "template": "treatment"
                }
            ]
        }
    ]
}