[Physician Letterhead] [Select Today`s Date] . [Name of Health

[Physician Letterhead]
[Select Today’s Date] .
[Name of Health Insurance Company]
[PO Box or Street Address]
[City], [State] [Zip Code]
Re: [Patient Name]
Policy Number: [Policy Number]
Group Number: [Group Number]
To Whom It May Concern:
[Patient Name] is a patient under my care for [disease]. She/he was first diagnosed with [diagnosis] on
[Select Diagnosis Date] . [Provide description of treatment and/or surgery that followed the diagnosis.]
At this time, I plan to start [Patient Name] on a course of treatment with [name of chemotherapeutic
agent], known to be emetogenic, and supportive [Drug name]. [Patient Name] will be treated with [state
dosing regimen].
Further, please note this patient has several additional risk factors that increase their overall risk profile
for developing chemotherapy-induced nausea and vomiting, including [age less than 60, female gender,
prior history of CINV or anticipatory nausea and vomiting, hyperemesis gravidarum, anxiety-related
mental health disorder, history of motion sickness, vestibular dysfunction, other functional or
If untreated, [Patient Name] may experience [state complications]related to her/his chemotherapy
treatment. In my professional opinion, [Drug name] is medically necessary and an appropriate drug for
my patient at this time. Enclosed is the package insert for [Drug name].
Please feel free to contact me if you require additional information. Enclosed you will find the patient's:
 [Prior failed medication]
 [Chemo flow sheets]
 [Chart notes]
 [Name of additional documentation]
[Physician Name, Signature]
Copies of patient medical records
[List enclosures]
[Drug name] package insert
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