September 14, 2026
Jordan Avery
1200 Example Lane
Louisville, KY 40200
Dear Jordan Avery (Medicaid ID DEMO000123):
Subject: Supports for Community Living Prior Authorization Approval
The services below have been prior authorized for the dates shown.
| Service | Units / Frequency | Begin | End |
|---|---|---|---|
| Behavior Support: H0004 | 12.00 per WK | 10/01/2026 | 03/31/2027 |
| Respite: T1005 | 960.00 per YR | 10/01/2026 | 09/30/2027 |
| Consultative Clinical and Therapeutic (Diet/Nutrition): H0004 | 30.00 per YR | 10/01/2026 | 09/30/2027 |
Provider: 7100000000, Sample Provider, LLC
Fictional letter for demonstration. No real person, member or provider is represented.