Date:________________

To: ___________________________
                (Insurance Company Name)
      ____________________________
                (Insurance Company Address)
      ____________________________
                 (Insurance Company Address)

Dear Sir or Madam:

I am requesting insurance coverage and reimbursement for my patient, _____________________________________, for whom I have prescribed the use of the 
                              (Patient’s Name)
Essential Amino Acid Module (manufactured by SHS North America).

The Essential Amino Acid Mix is indicated for the dietary management of urea cycle disorders and represents an important part of the treatment regimen. To our knowledge, it is the only premixed essential amino acid preparation available. As a medical food it is not generally available at the retail level, but needs to be special ordered from a pharmacist. Medical supervision is necessary.

The Essential Amino Acid Mix is prescribed and is medically necessary in this instance as the optimum treatment for __________________________________________ with a
                                                                                                (Patient’s Name)
diagnosis of _______________________________________. I respectfully request insurance reimbursement/coverage for the Essential Amino Acid Mix. The reimbursement code for this product is 49735-0114-90.

Sincerely,

___________________________________________