NY Manual
SHP Manual

SHP Provider Manual
3.2a Sample Service Plan Letter (Page 1) | 3.2b Sample Service Plan Update Letter (Page 1)

3.2 a Sample Service Plan Letter (Page 2)

Authorized Service(s) and/or Item(s):

Requesting Provider: <<rp_full_name>>

Requested Date(s) or Service(s): <<re_referral_start_date>>-<<re_referral_end_date>>

Service(s)/Procedure(s)/Units(s): <<re_units_authorized1>>

Service Description: <<re_procedure_code1>>

Authorization Number: <<re_authorization_number>> 

 

Requesting Provider: <<rp_full_name>>

Requested Date(s) or Service(s): <<re_referral_start_date>>-<<re_referral_end_date>>

Service(s)/Procedure(s)/Units(s): <<re_units_authorized1>>

Service Description: <<re_procedure_code1>>

Authorization Number: <<re_authorization_number>> 

 

 
 
 

<<SHP_28 01/2011>>