Medical Necessity Letter Request Log PDF
Track requests for medical necessity letters and follow-ups with providers in a narrow PDF-ready log.
Letter requests
Log provider requests for medical necessity letters, delivery, and follow-ups.
| Request Date | Provider / Clinic Name | Provider Phone / Fax / Portal | Patient Name or Initials | Insurance Company | Claim / Auth # | Service / Procedure | Requested Delivery Method | Follow-Up Date | Status / Notes | Actions |
|---|---|---|---|---|---|---|---|---|---|---|
Download a narrow request log PDF to include with your appeal packet.
🔒 MANDATORY CODEX SAFETY FOOTER (INCLUDE VERBATIM)
Non-Negotiable Guardrails
- Do not modify global layout, header, footer, ads, analytics, or shared components
- Do not import @/components/ui/select or any unverified shadcn components
- Use native HTML inputs only
- Row add/remove buttons must be plain <button>
- No date math, no parsing, no calculations
- PDF builders must return Promise<Uint8Array>
- Always create Blobs using bytesToPdfBlob(bytes) from lib/pdf/bytes.ts
- Never include null in React-PDF style arrays
- No refactors
- Tool may only break itself
Safety notes
- Processing stays in your browser. PDFs generate locally—no uploads or accounts.
- Downloads use a secure PDF blob helper (no raw array buffers or workers required).
- Review details before sending; nothing here is legal advice or a substitute for local forms.