Coding & Reimbursement / Downloadable Letters & Forms
Downloadable Letters & Forms
Note: All documents are less than 112 KB
- Sample Letter of Medical Necessity (PDF | Word)
- Sample Letter of Appeal Prior-Auth Denial (PDF | Word)
- Sample Letter of Request for Appeal – Claim Denial (PDF | Word)
- Sample Medicare Advanced Beneficiary Notice (ABN) For Use of The Spanner™ Prostatic Stent (PDF | Word)
- Sample
Waiver of Liability Form (PDF | Word)
- Sample Prior-Authorization Request Form (PDF | Word | Excel)
- Sample Prior-Authorization Call Tracking Form (PDF | Word | Excel)
- FDA Approval Letter (PDF)
