The Safety Sleeper

Example of Letter of Medical Necessity - 400 Model

December 18, 2020

PATIENT: Adam Smith, Male
DOB: November 7, 2010
Abram’s Nation
4726 Highpoint Drive
Gibsonia PA, 15044

To Whom It May Concern,

{ENTER CHILD’S STORY} Adam was born prematurely and suffered a brain bleed at birth. He was hospitalized in the NICU from November 7 to December 1, 2010. Adam has global Developmental Delay (GDD) and he has had major delays in attaining his gross and fine motor milestones, and severe delays in speech/comprehension. At 22 months old, he does not know his own name, he cannot point, and he is unable to comprehend or follow any simple commands. A child psychologist at the Glenrose Rehabilitation Hospital has assessed Adam as possibly having an Autism Spectrum Disorder on September 14, 2014.

When attempting to put Adam to bed, he flaps, kicks, rolls, and head-butts. He is not safe in a regular crib. He repeatedly hits the crib rails and injures himself. His parents watch him on a video monitor to ensure that he sleeps. {ENTER ALL EXAMPLES YOU HAVE TRIED TO KEEP CHILD SAFE AT NIGHT}.

Adam has recently learned how to pull himself to a stand and walk. He requires constant 1:1 adult supervision to prevent injuries while walking, since he has low truncal tone and a very unsteady gait. He frequently trips and falls.

Adam has grown in strength, height and weight (roughly 35” tall, 28lbs). He is now able to rock the sides of the cot and is attempting to climb out of it. If he managed to get out of the cot, he would risk serious injuries from tripping/falling and hitting his head on the wall, the floor, or on furniture.

The Safety Sleeper is medically necessary for Adam Smith because:

We are recommending the child obtain the following model of The Safety Sleeper: Queen Size, 400 model with the following accessories:

The Safety Sleeper is made with medical fabric. The fabric is encased with dense foam on the top and on the sides of the enclosure. This ensures that the child is protected from the metal frame. The Safety Sleeper also comes with two coverlets that replace the need for a fitted sheet. The coverlet zips directly into The Safety Sleeper to protect against all entrapment zones. Coverlets are only accessible by the caregiver and can be easily removed to launder separately from the enclosure. The Safety Sleeper also comes with stabilizing straps that are secured around the bedframe to prevent tipping or moving. Recommended to counteract obstreperous activity. These are attached to The Safety Sleeper and can be used with your traditional bed frame. The entire Safety Sleeper system will help prevent Adam from any unsupervised night wandering and dangerous physical injury due to his major cognitive and physical limitations from his Global Developmental Delay and possible Autism Spectrum Disorder.

Finally, we recommend a safe sleeping environment for this child because, without it, he would severely injure himself. It will also ensure Adam has a safe and secure sleep environment which will provide the restorative sleep that he needs.

Please feel free to contact me if you have any questions,


{INSERT DOCTOR'S NAME AND CONTACT INFORMATION} Items to include: Diagnosis, purpose, selection process including previous equipment, list of equipment needs


Download this example letter as a PDF