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Free Medical Benefits Request - Authorization for Additional Services

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_________________, _________________ _________________

 

_________________

 

_________________

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_________________, _________________ _________________

 

Dear _________________:

 

Re: Policy Number: _________________

Dependent Name: _________________

 

Dear _________________:

 

My _________________ is covered under the plan listed above. _________________ suffers from _________________. We have consulted with our primary care physician regarding this condition, and have followed all of that doctor's recommendations for treatment. However, _________________ is not improving.

 

After extensive consultation with _________________, we now believe that the only way that this condition will be alleviated is for _________________ to _________________ _________________. This _________________ is not available within the network of services you provide.

 

I urgently request that you review this case and authorize us to go out of network in order to obtain the treatment that _________________ requires. Enclosed you will find letters from the physicians we have consulted in which they advise this treatment as the most likely to produce complete recovery.

 

Please give this situation a high priority. _________________'s condition is declining, and we wish to begin treatment very soon.

 

Sincerely,

 

 

 

_________________

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