Resources and forms for every step along the way

Start Form

Start Form – Spanish

Prior Authorization & Appeals Guide

Letter of Medical Necessity Checklist

Sample Letter of Medical Necessity

Letter of Medical Exception Checklist

Sample Letter of Medical Exception

Letter of Appeal Checklist

Sample Letter of Appeal

Patient Co-pay Checklist

Provider Co-pay Checklist

Co-pay Flashcard

Co-pay Portal Overview

Patient and Provider Co-pay Claim Form

Specialty Pharmacy Commercial Co-pay Claim Form

LEQVIO Prescription Considerations

Buy-and-Bill 5 Step Guide

Buy-and-Bill Checklist

Distribution & Acquisition Flashcard

Alternate Site of Care Referral Guide

Alternate Site of Care Referral/Order Form

Alternate Site of Care Clinical Documentation Referral
Checklist

LEQVIO Patient Tracker

LEQVIO Patient Management Tracker

Billing & Coding Guide

Claim Filing Checklist

Annotated CMS-1500 Form

Annotated CMS-1450 (UB-04) Form