Medical Claim Letter - Template, Sample Form Online Pro · US-law

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Phone: ________
Email: ________

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Attn: Claims Department
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RE:   Insurance Claim Submission
Policy Number: ________
Group Number: ________
Claim/Reference Number: ________
Insured/Member Name: ________
Member ID Number: ________

Dear Claims Administrator:

I am writing to ________ (the “Insurer”) to formally submit a claim for benefits under the above-referenced policy of insurance. This claim is made in accordance with the terms and conditions of the policy and all applicable provisions of federal and state law, including, where applicable, the Employee Retirement Income Security Act of 1974, as amended (29 U.S.C. § 1001 et seq.), and the insurance laws and regulations of the State of ________.

The particulars of the claim are as follows:

Patient: ________

Patient Date of Birth: ________

Relationship to Insured: ________

Provider: ________

Provider Tax ID / NPI: ________

Date(s) Services Rendered: ________

Description of Services: ________

Total Amount Claimed: ________

In support of this claim, I have enclosed the following documentation:

— A completed and signed claim form;

— An itemized statement and/or bill from the provider;

— Proof of payment, where applicable;

— ________

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If any additional information, documentation, or follow-up is required to process this claim, please contact me by telephone at ________ or by email at ________.

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Sincerely,

_______________________________
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Enclosures