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 Patients 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's Signature
Physicain's Name
Physician's Address