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| Copy of patient's insurance card, front and back | |
| Letter of medical necessity from referring physician | |
| Authorization letter (if required by the insurance plan), including the authorization number and CPT codes authorized. OR | |
| If no authorization is necessary, note the name and extension of the plan employee who provided this information. | |
Links to Forms
Authorization to bill insurance
Sample letter of medical necessity
Checklist for creating a letter of medical necessity
Please note: We are not able to bill non-contracted plans, even if the plan authorizes the medical service.
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