MEDICAL CLAIM LETTER

[INSERT THE NAME OF THE SENDER]

[INSERT ADDRESS OF THE SENDER]

Date:

[INSERT THE NAME OF THE INSURANCE COMPANY]

[INSERT ADDRESS LINE OF INSURANCE COMPANY]

SUBJECT: Medical Claim Submission for [INSERT THE NAME OF THE PATIENT]

Dear [INSERT INSURANCE COMPANY OR HEALTHCARE NAME]

I am writing to formally submit a claim for medical expenses incurred by [INSERT THE NAME OF THE PATIENT], who is covered under the Policy Name [INSERT POLICY NAME AND PATIENT’S ID].

Please find the attached details of the medical services provided to the [INSERT THE NAME OF THE PATIENT].

Provider’s Name: [INSERT HELATHCARE PROVIDER’S NAME]

Date of service: [INSERT DATE OF SERVICES]

Description of Services: [INSERT DETAILED DESCRIPTION OF MEDICAL SERVICES PROVIDED]

Below are the Claim Details:

Amount Charged: [ INSERT TOTAL AMOUNT CHARGED]

Amount covered by Insurance Company: [INSERT AMOUNT COVERED NY INSURANCE COMPANY]

Amount Paid by Patient: [INSERT AMOUNT PAID BY PATIENT]

(Attach any documents to support this claim)

Please process this claim at your earliest convenience and inform me of any additional information or documentation required. Feel free to contact me at [INSERT YOUR CONTACT NUMBER] if you need any further assistance.

Thank you for your prompt attention to this matter. I look forward to your response.

Sincerely,

SENDER’S SIGNATURE

[INSERT NAME/DESIGNATION OF SIGNING AUTHORITY OF SENDER]

SENDER’S NAME