________
________
________
________
________
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
________
As a result, I am claiming reimbursement in the amount of $________ (________). This can be paid in the following manner:
________
52 522 5558282258 228828 52 88 52858525, 282582 8222582 22 58822 252 5225888 58282. Thank you for your prompt attention to this matter.
Yours faithfully,
________
________
________
________
________
________
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
________
As a result, I am claiming reimbursement in the amount of $________ (________). This can be paid in the following manner:
________
52 522 5558282258 228828 52 88 52858525, 282582 8222582 22 58822 252 5225888 58282. Thank you for your prompt attention to this matter.
Yours faithfully,
________
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