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:
Physician Name:
		Patient Name:
		Address:
		City:
		State: Zip:
Dear:		Medical Director or Insurance Executive:
		Subscriber Name:
		Group Policy Number:
		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.