Medical Insurance Layout Claim Letter
April 15, 2051
Claims Department
PureWave
707 Elm Drive,
Lakeside, NY 10015
Dear Claims Department,
I am writing to formally submit a claim for medical services provided on March 5, 2051. I am a policyholder under your insurance policy #ABC1234567 and seek reimbursement for the expenses incurred for my medical treatment.
Below are the details of my claim:
Policyholder Name: [Your Name]
Policy Number: ABC1234567
Date of Service: March 5, 2051
Healthcare Provider: Dr. Evelyn Scott, New York Medical Clinic
Description of Services: Physical examination, X-ray imaging, and consultation for a knee injury
Total Claim Amount: $1,200
I have attached the following documents to support my claim:
Itemized medical bill from New York Medical Clinic.
Payment receipts for the services rendered.
Medical records and reports detailing the treatment.
Authorization letter from PureWave for X-ray services.
Please review this information and process my claim for reimbursement as outlined in my insurance policy. Should you require any additional information, feel free to contact me at 222 555 7777 or via email at [Your Email].
Thank you for your attention to this matter. I look forward to your prompt response and the reimbursement of the claim.
Sincerely,
[Your Name]
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