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(Date of Letter)

(Hospital/Care Provider) (Street Address) (City, State and Zip Code) RE: Attn: Insurance Coverage Accounting Department

Dear Accounting Department: Apparently some misunderstanding has arisen relative to the insurance coverage regarding the following individual: (name of individual). This individual received care from your facility from the day of (month/year), until the day of (month/year). Please be advised that this individual was covered under an insurance policy identified as: (name of insured and insurance policy number). Please be further advised that this insurance coverage was in full force and effect at the time the treatment was received by the aforementioned individual. It would appear as though your office did not have the appropriate information relative to this insurance coverage at the time billing was submitted; therefore, the foregoing information is provided to you for clarification. Kindly submit your statement for services to the aforementioned carrier with reference to the policy number and the name of the insured in order to assure proper payment for your services. Please be assured that the undersigned will cooperate in every way possible to be certain that this statement is satisfied in conjunction with the policy noted above. In the event there are any sums due and owing in excess of the coverage, same will be provided by (name of individual responsible for payment of amounts in excess of insurance coverage). Should you have any questions relative to the foregoing, please do not hesitate to contact the undersigned. Thank you. Very truly yours,

(Signature) (Address) (City, State and Zip Code) (Phone Number) LAWCHEK, LTD. LETTER PRO Samples, Copyright 2000 This is not a substitute for legal advice. An attorney must be consulted.