Forms and Documents for Vaprisol
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 Denial Appeal (PDF - 145 KB)
- Sample CMS-1450 (UB-04) Claim Form (PDF - 586 KB)
Quarterly Coding and Billing Reference Sheets
- Second Quarter 2012 (4/1/12 - 6/30/12) (PDF - 577 KB)
- First Quarter 2012 (3/1/12 - 3/31/12) (PDF - 575 KB)
