Printable Medical Forms
File Medical Claim Letter Medical Form


Susie Queue

123 Main St.

Anytown, CA 95928

(555) 555-1212

 

August 14, 2021

 

ABC Insurance

345 Any Place.

Anytown, CA 95928

 

To whom it may concern,

 

I am writing regarding a medical claim under policy number: ___________________

 

 

Here is the claim information:

 

Patient:

 

Provider:

 

Date:

 

 

I have attached a completed claims form, along with a statement from the provider.


I look forward to the prompt processing of this claim. Thank you.

 

Sincerely,

 

 

 

Enclosure: claims form











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