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RE: Policy Number ________
To Whom It May Concern,
I am writing to ________ to file a claim for the following:
Patient: ________
Provider: ________
Date Services Rendered: ________
I have enclosed the following supporting documentation:
A completed claims form
A statement from the provider
Evidence of the expenses which have been incurred
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As a result, I am claiming reimbursement in the amount of $________ (________). This can be paid in the following manner:
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Yours faithfully,
________
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