Forms and Documents for Adenoscan
We've provided a number of different forms and letters to help you.
Please note: Forms for Benefit Verification and Stock Replacement Requests are no longer available on this site. For your convenience Benefit Verification Requests and Stock Replacement Requests can now be submitted conveniently online via Astellas eService
If you don't see a form you need, please contact us at 1-800-477-6472.
- Patient Authorization to Disclose Health Information (HIPAA) (PDF - 123 KB)
- Sample Letter of Medical Necessity (PDF - 102 KB)
- Sample Letter of Denial Appeal (PDF - 102 KB)
- Sample Letter of Medicare Carrier Advisory Letter (PDF - 94 KB)
- Sample CMS-1450 (UB-04) Claim Form (PDF - 590 KB)
- Sample CMS-1500 Claim Form (PDF - 733 KB)
Quarterly Coding and Billing Reference Sheets
- Second Quarter 2012 (4/1/12 - 6/30/12) (PDF - 254 KB)
- First Quarter 2012 (3/1/12 - 3/31/12) (PDF - 253 KB)
