You may also ask us for a coverage determination by phone at 1-844-969-5366 or through our website at www.leonhealth.com.
Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.
All fields with (*) are required.
Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or 1-800-Medicare.
If known, include strength and quantity requested per month
Attach any supporting documents
Max. file size: 15 MB, Max. files: 3.
Diagnosis and Medical Information