Free Prior Authorization Fax Cover Sheet Template
Prior Authorization Fax Cover Sheet
FAX |
To: [RECIPIENT'S NAME]
From: [YOUR NAME]
Company: [YOUR COMPANY NAME]
Email: [YOUR EMAIL]
Date: June 11, 2053
Fax no.: 123456789
Re: Request for Prior Authorization - [Patient's Full Name]
Message
Dear [Recipient's Name],
I trust this letter finds you well. Enclosed is the formal request for prior authorization on behalf of [Patient's Full Name], essential for [Reason for Authorization]. We appreciate your prompt attention.
Request details:
-
Patient: [Patient's Full Name]
-
Date of Birth: [Patient's DOB]
-
Policy/Case Number: [Policy/Case Number]
-
Requested Procedure: [Description of the Procedure]
-
Date of Procedure: [Scheduled Date]
Your cooperation is invaluable in securing approvals for the patient's well-being. Thank you in advance for your pivotal role.
For queries or clarification, reach our dedicated authorization team.
Thank you for your time.
Sincerely,
[YOUR NAME]
[YOUR POSITION]
[YOUR COMPANY NAME]
