________
________
________
________
________
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 $________ (Australian dollars). This can be paid in the following manner:
________
If any additional follow up is required, please contact me using the details above. 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 $________ (Australian dollars). This can be paid in the following manner:
________
If any additional follow up is required, please contact me using the details above. Thank you for your prompt attention to this matter.
Yours faithfully,
________
Use the form on the left to fill in the template.
The document is written according to your responses - clauses are added or removed, paragraphs are customised, words are changed, etc.
At the end, you will immediately receive the document in Word and PDF formats. You can then open the Word document to modify it and reuse it however you wish.