We've provided a number of different forms and letters to help you. If you don't see a form you need, please contact us at
- Benefit Verification Request Form (PDF - 126 KB)
- Stock Replacement AAP Application (PDF - 159 KB)
- Patient Authorization to Disclose Health Information (HIPAA) (PDF - 108 KB)
- Sample Letter of Medical Necessity (PDF - 224 KB)
- Sample Letter of Denial Appeal (PDF - 247 KB)
- Sample Letter of Medicare Carrier Advisory Letter (PDF - 217 KB)
- Sample CMS-1500 Claim Form (PDF - 508 KB)
- Quarterly Coding and Billing Reference Sheets
- Third Quarter 2010 (7/1/10 – 9/30/10) (PDF - 225 KB)
- First Quarter 2010 (1/1/10 – 3/31/10) (PDF - 224 KB)
- Fourth Quarter 2009 (10/1/09 – 12/31/09) (PDF - 159 KB)
- C-code Information
- C-Code Reference Sheet (PDF -653 KB)
- C-Code Announcement (PDF - 246 KB)
- VIBATIV Coding Aid
- VIBATIV Coding Aid (PDF - 243 KB)
- MAC Submission Checklists
- Flashcard Checklist Part B (PDF - 179 KB)
- Flashcards by Jurisdictions
- Cahaba GBA Flashcard (PDF - 1.6 MB)
- Cigna Flashcard (PDF - 1.0 MB)
- First Coast Service Options Flashcard (PDF - 1.5 MB)
- Highmark Medicare Services Flashcard (PDF - 1.5 MB)
- National Government Services Flashcard (PDF - 2.2 MB)
- National Heritage Insurance Company Flashcard (PDF - 1.5 MB)
- Noridian Administrative Services Flashcard (PDF - 1.8 MB)
- Palmetto GBA Flashcard (PDF - 1.9 MB)
- Pinnacle Medicare Services Flashcard (PDF - 1.6 MB)
- Trailblazer Health Enterprises Flashcard (PDF - 1.6 MB)
- Wisconsin Physicians Health Insurance Flashcard (PDF - 1.7 MB)
