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)