Sample Medical Supplies and Equipment Prior Approval Confirmation Letter
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Medical Supplies and Equipment Prior Approval Confirmation Letter
Health Canada Protected
From Address
Approval Date (Prior Approval Date)
To Address (Provider)
Re: Confirmation of Prior Approval
Client # (Blank If Infant)
Surname
Given Name
Band Number
Family Number
Date of Birth dd/mm/yyyy format
Parent Number (For Infants Only)
This is to confirm that prior approval number has been issued for the
provision of the following item(s), except where indicated:
Item Code
Item Name
Quantity
Fee
Refill #
Markup
Third Party
Total Approved
Not Approved
Start Date
Expiry Date
Min Qty Per Claim
General Comments
Note: Please quote Prior Approval Number on your claim submission.
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