Forms and Documents

• Patient Enrollment Form
  (PDF - 260 KB)
• PADCEV Coding and Billing Guide
  (PDF - 5.12 MB)
• Sample CMS-1450 (UB-04) Claim Form
  (PDF - 120 KB)
• Sample CMS-1500 Claim Form
  (PDF - 468 KB)
• Sample Letter of Medical Necessity - Medical Benefit
  (PDF - 116 KB)
• Checklist for Requesting Prior Authorization
  (PDF - 84 KB)
• Sample Letter of Denial Appeal - Medical Benefit
  (PDF - 124 KB)
• Checklist for Appealing Denied Claims
  (PDF - 124 KB)