Dear Caregiver,

We are here to help you obtain a Safe Place Bed for your loved one. Insurance companies require us to obtain several items to help them determine if there is a medical necessity or special need for this bed. These items include a prescription, a Letter of Medical Necessity (LMN) and Medical Records documenting diagnoses and issues contributing to the need for a Safe Place Bed. You can help us gather the needed information by completing this questionnaire. We will share this with your child’s physician to help him or her write the required Letter of Medical Necessity. Please make us aware upon completion of this questionnaire if your child has been seen by any other professional relating to their need for a safe place to sleep so
we may contact them, also. These professional could include a Physical Therapist (PT), Occupational Therapist (OT), Sleep Study Professional, Psychiatrist, and an Assistive Technology Professional (ATP).

Common Covered Diagnoses:
- Self-injurious Behaviors
- Elopement Risk (escaping the house)
- Muscle conditions (especially cerebral palsy)
- Seizure disorders
- Movement disorders
- Severe behavioral disorders
- Cognitive impairment or developmental disability
- The inability to communicate verbally.
- Balance problems (including the inability to sit up)

PLEASE NOTE: Insurance companies will not accept just one diagnosis, such as Autism or Cerebral palsy. They want to know in what way the child’s diagnosis affects his or her sleep and what Special Needs the child has, to warrant them paying for a specialty bed. Please complete the questionnaire on the next page and return it to us as soon as possible. We will then contact your child’s doctor and any other medical professional you mention to obtain the necessary documents so we may begin the Prior Authorization process. Depending on the insurance company, this process takes 2-4 weeks.

Thank you,
Safe Place Bedding, LLC