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Step {{index}} of {{steps.length-1}}

Prior Authorization Drug Denial Letter Template

Complete the following steps to create an individualized letter appealing a denial for a prescribed treatment for your patient.

Dermatologic disease with ICD-10 diagnosis code *

Name of drug *

Alternative Treatment Drug Options

For step therapy protocols, select drug/treatment the insurance company is requiring you to prescribe your patient as an alternative treament (skip if not applicable)

* = required field

Back

* = required field

Back

Patient name *

Patient health insurance identification number *

Patient date of birth *

Date of prior authorization *

* = required field

Back

I have previously prescribed this patient the following therapies (optional):

Prescribed from {{ convertDatePickerDate(medication.startDate) }} to {{ convertDatePickerDate(medication.endDate) }}

Reasoning: {{ medication.stopReason }}

Name of medication

Dates prescribed

From

Reason for stopping medication

* Please fill out all fields

Back

Click the button below to download your prior-authorization letter template.

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Test Page 2

{{ steps[index] }}

Prior Authorization Drug Denial Letter Template

Dermatologic disease with ICD-10 diagnosis code *

Name of drug *

Alternative Treatment Drug Options

Name of medical director

Insurance company name *

Insurance company address *

Insurance company city, state, zip *

Patient name *

Patient health insurance identification number *

Patient date of birth *

Date of prior authorization *

I have previously prescribed this patient the following therapies (optional):

{{ medication.medName }}

Name of medication

Dates prescribed

Reason for stopping medication

Click the button below to download your prior-authorization letter template.

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Test Page 2

{{ steps[index] }}

Prior Authorization Drug Denial Letter Template

Dermatologic disease with ICD-10 diagnosis code *

Name of drug *

Alternative Treatment Drug Options

Name of medical director

Insurance company name *

Insurance company address *

Insurance company city, state, zip *

Patient name *

Patient health insurance identification number *

Patient date of birth *

Date of prior authorization *

I have previously prescribed this patient the following therapies (optional):

{{ medication.medName }}

Name of medication

Dates prescribed

Reason for stopping medication

Click the button below to download your prior-authorization letter template.

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