Directions:

1. Type the appropriate information into the fields below to personalize your copy of the letter
2. Click the Submit button, this will generate your personalized letter
3. Print a copy of the letter or highlight the text of the letter, copy it and paste it into your own word processing document.

Date:
Subscriber Name:
Group Policy Number:
Attn:		Medical Director or Insurance Executive:
Re:		Patient Name:
		Chief Complaint:
		History:
		Examination:
		No patient information entered in these forms is stored in any way by Athena. This form is created simply to facilitate your use of this template.