SAMPLE LETTER FOR
SUPER SOLUBLE DUOCAL®
Date: _____________
Company Name: _____________
Street Address: _____________
City, State and Zip: _____________
RE: _____________ (Patient Name)
Dear Sir or Madam:
On behalf of my patient, Patient's name, I am submitting this letter to explain the medical condition for which I prescribe Super Soluble Duocal®
Explain medical diagnosis and treatment.
Super Soluble Duocal® is a high calorie-protein free nutritional supplement ideal for medical conditions where extra calories are required. It contains a blend of carbohydrate and fat in a powdered formula and is completely soluble in water, liquids, and moist foods. Super Soluble Duocal®; does not alter the taste of foods. Super Soluble Duocal®; is protein, lactose, gluten free, and very low in electrolytes.
Super Soluble Duocal® is prescribed and is medically necessary in this instance as the optimum treatment for ________________ (Patient Name) with a diagnosis of _________________ (Diagnosis).
I respectfully request insurance reimbursement/coverage for Super Soluble Duocal®;
The reimbursement code for this product is 49735-0102-80.
Sincerely,
_________________
(Physician Signature)
_________________
(Physician Name)
_________________
(Physician Address)