Forms and Documents for Mycamine
We've provided a number of different forms and letters to help you.
Forms for Benefit Verification and Patient Assistance Requests are no longer available on this site. For your convenience Benefit Verification Requests and Patient Assistance 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 - 121 KB)
- Sample Letter of Denial Appeal (PDF - 148 KB)
- Sample Letter of Medicare Carrier Advisory Letter (PDF - 123 KB)
- Sample CMS-1450 (UB-04) Claim Form (PDF - 580 KB)
- Sample CMS-1450 (UB-04) Claim Form (PDF - 580 KB)
- Sample CMS-1500 Claim Form (PDF - 722 KB)
Quarterly Coding and Billing Reference Sheets
- Second Quarter 2012 (4/1/12 - 6/30/12) (PDF - 610 KB)
- First Quarter 2012 (3/1/12 - 3/31/12) (PDF - 609 KB)
Mycamine Coding Aid
- Mycamine Coding Aid (PDF - 233 KB)
