-Sample Letter of Medical Necessity - SADS

Ventricular arrhythmia ICD Code: Date of diagnosis: ( Heart block ICD Code: Date of diagnosis: ( Valvular heart disease ICD Code: Date of diagnosis: ... ( Supraventricular tachycardia (If checked, indicate frequency): ( Constant ( Intermittent (paroxysmal) (If “Intermittent,” indicate number of episodes in the past 12 months): ................
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