Heron Connect^® Downloadable Resources

Sample CMS-1450 (UB-04) Claim Form

Sample form with annotations and instructions.

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Sample CMS-1500 Form

Sample form with annotations and instructions.

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Coding Reference Guide

Listing of Diagnostic, NDC, HCPCS, CPT, and Revenue Codes for SUSTOL^® .

SUSTOL product-specific J-Code is J1627.

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Sample Letter of Medical Appeal

A letter with a customizable template for you to use if a health plan denies your patient access to SUSTOL.

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Sample Letter of Medical Necessity

A customizable letter your practice can use to provide health plans with a brief medical rationale for the use of SUSTOL.

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Distribution Reference Guide

For explaining how and where to order SUSTOL^® .

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Heron Connect Reimbursement Support Reference Guide

Reference guide describing the Heron Connect Programs and Services.

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Heron Commitment Program^® Flashcard

Highlights the coverage denial support provided to your practice through the Heron Commitment Program.

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Product Replacement Policy Flashcard

Highlights the product replacement policy offered to healthcare providers or direct purchasing customers through Heron Connect.

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Insurance Verification and Program Enrollment Form

One single form used to verify benefits and enroll patients in Heron Connect Programs.

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Practice Copay Assistance Program Enrollment Form

A one-time form your practice must complete in order to participate in the simplified Heron Connect Copay Assistance Program registration process.

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Patient Copay Assistance Program Registration Form

A form used to enroll individual patients solely into the Heron Connect Copay Assistance Program. The one-time Practice Copay Assistance Program Enrollment Form must also be completed.

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Heron Commitment Program^® Enrollment Form

A form your practice must complete in order to be eligible for the Heron Commitment Program.

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Payer Policy Guide

Reference guide highlighting Commercial and Medicaid coverage and policy information for SUSTOL^® .

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Instructions for Use (IFU)

A document with information about the preparation and administration of SUSTOL^® .

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Administration Tear Sheet

Illustrated overview and helpful hints to administer SUSTOL.

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Patient Education Flashcard

A flashcard that provides important information about what your patient can expect when receiving SUSTOL.

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