Authorization Letter

This template may be used to create a letter of medical necessity for any of Athena’s tests. You may choose to download the blank Word document or use the convenient form template below. Be sure to view our test catalog or requisition for the appropriate name of the test and to obtain the appropriate CPT codes for the test. If we can be of further assistance, please contact us at (800) 394-4493.

Physician InformationPatient & Insurance InfoDisorder and Test Information

Physician Information

Name:
NPI#:
Hospital/Institution:
Address:
Address 2:
City:
State:	Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
Zip:
Phone Number:

Patient Information

Patient Name:
DOB: (MM/DD/YYYY)
Gender:	male female

Insurance Information

Medical Director Name:
Insurance Company:
Insurance Company's Address:
Address 2:
City:
State:	Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming
Zip:
Member ID:
Group ID:

Disorder and Test Information

Name of Suspected Disorder:
Name of Athena Test:
CPT Codes: Separate by comma or copy and paste from website	Search for CPT codes
List Primary Clinical Symptoms:	1. ICD-9: 2. ICD-9: 3. ICD-9:
Family History:
Benefits of Testing:	1. 2. 3.
Reason for Using Athena:	Example: Athena is the only Lab that can perform this testing; Athena's test has a higher sensitivity than other labs