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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;
— ________
If any additional information, documentation, or follow-up is required to process this claim, please contact me by telephone at ________ or by email at ________.
Sincerely,
_______________________________
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Enclosures
Fields you complete are inserted into the document live. This template is general guidance only - not legal advice.