PET Center Name
PET Center Address
PET Center Phone and Fax Number
Patient Name:
Policy Number:
Date of Service:
To Whom It May Concern:
( name of patient)
diagnosis) on ( date)
is a ( age ) year old ( female- Male) who was diagnosed with (
( Second Paragraph) Description of cancer. This will include, metastatic spread,
survival statistics and recurrence rate – whatever pertains to this specific patients
disease
( Third Paragraph) This paragraph lists, any surgeries, imaging or treatments the
patient had and the reason for her PET/CT scan- this paragraph is patient specific
( Fourth Paragraph) Explain with facts, why PET/CT was important to patient’s
diagnosis or treatment. Include article with letter if possible
Please reconsider payment for ( name of patient) PET/CT scan done on ( date) as it
was ( fill in why PET/CT was helpful to patient)
Thank you for your time and consideration.
Sincerely,