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RE: Policy Number ________

Dear Sir or Madame,

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

-- ________

If any additional follow up is required, please contact me by phone at ________.

Thank you for your prompt attention to this matter.

Best,

________

Enclosures