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RE: Policy Number ________
Dear Sir or Madame,
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
-- ________
If any additional follow up is required, please contact me by phone at ________.
Best,
________
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