From Individual to Insurance Company
Documenting claim to medical insurance carrier
From customer to insurance company
Regarding member number: 123098567
Enclosed please find documents to support my claim for reimbursement of medical expenses incurred while traveling away from my home.
As indicated on your Web site, I am providing the following documents:
An invoice showing expenses paid to an emergency medical facility in Chillicothe, Ohio;
A detailed doctor’s report from the emergency medical facility, including diagnosis, services performed, and medications prescribed;
A receipt for prescription medications related to this illness; and
Copies of hotel and airline ticket receipts that document the starting and ending date of this trip away from home.
The total amount for out-of-home-area medical expenses was $1,546.23.
I have also included a signed copy of your medical claim form. Please keep me posted on the progress of my claim and advise me of any questions related to this claim.
Request to medical insurance company for formal written ruling on claim
From individual to insurance company
Regarding policy #459801020
Policyholder name: Thomas Poster
Claim #H4-2361A
August 12, 2007
I am writing to request an update on the status of my claim for reimbursement for medical expenses incurred while I was on a trip in Europe. I submitted the claim and necessary forms more than five weeks ago, on July 5, 2007.
I would appreciate a statement of coverage and a check as soon as possible so that I can submit a claim to a secondary medical insurance company.
Contesting primary medical insurance claim denial
From individual to insurance company
Regarding policy #459801020
Policyholder name: Thomas Poster
Claim #H4-2361A
August 12, 2007
I am writing to formally contest your company’s denial of my claim for reimbursement of expenses incurred on an international trip.
According to your representative in a telephone conversation on July 30, 2007, my insurance policy should cover all out-of-area medical expenses minus a copay of $500. I was given the following confirmation code for our telephone conversation: AMGUIE H.
Please advise me of the progress of my reinstated claim as soon as possible.
Transmittal to secondary medical insurance company of claim
From individual to insurance company
Regarding policy #ST02929
Policyholder name: Thomas Poster
August 12, 2007
I am a policyholder in your Worldwide Travel Plan Insurance. Enclosed please find a statement of coverage and claims paid by my primary health insurance company for medical expenses incurred while I was on a trip in Europe. Also included is the claims form from your company and an affidavit of the circumstances of my illness and the dates of travel away from my home area.
I am now requesting your company accept my claim for the portion of my expenses that were not covered by my primary insurance carrier.
Notifying insurance company of change of address
From individual to insurance company
Regarding policy #459801020 Policyholder name: Jeremy Stein Date of birth: April 3, 1916
Please change your records to indicate my new permanent address, listed below.
| Former address: | (Address) |
| New address: | (Address) |
| Telephone: | (Telephone number) |
Notifying life insurance company of death of policyholder
From individual to insurance company
Regarding policy #459801020
Policyholder name: Jeremy Stein
Date of birth: April 3, 1916
I am writing to request necessary forms to file a life insurance claim for the above policy. Jeremy Stein died on May 15, 2008, at Lumbertown Community Hospital. Mr. Stein was my uncle, and I am listed with your company as a beneficiary; I also am listed on Mr. Stein’s records as an attorney-in-fact under a Durable Power of Attorney.
(Name)
(Address)
(Phone number)
Notifying life insurance company of change of name
From individual to insurance company
Regarding policy #459801020
Policyholder name: Maribeth Plame
Date of birth: April 3, 1986
Please change your records to indicate a change of name; I was married June 5, 2007, and have taken my husband’s name as part of my own.
| Former name: | Maribeth Plame |
| New name: | Maribeth Plame-Kineck |
| Address: | (Address) |
| Telephone: | (Telephone number) |
Notifying insurance company of changes to policy because of divorce
From individual to insurance company
Regarding policy #459801020
Policyholder name: Maribeth Plame-Kineck
Date of birth: April 3, 1986
Please change your records to reflect the following changes which are due to a decree of divorce that was granted June 4, 2008. A copy of the final decree is attached.
| Former Name: | Maribeth Plame-Kineck |
| New Name: | Maribeth Plame |
| Address: | (Address) |
| Telephone: | (Telephone number) |
Please also remove David Kineck as one of the beneficiaries on my policy. At this time it is my intent that any proceeds from my policy will go to my parents Jack and Jill Plame, who are currently listed on the policy as secondary beneficiaries.
From Individual to Medical Office
Requesting transfer of medical records from one doctor to another
From individual to doctor or medical institution
(NOTE: Some doctors or medical institutions may require use of their own forms to request transfer of records. You can seek release of your records with your own letter, but they may respond with a form for you to fill out.)
I hereby authorize (name of doctor or medical organization) to release to (name of new doctor or medical organization) a copy of the full set of my medical records in your possession.
Please send the files to:
(New medical provider)
(Address)
(Phone number)
| ______________ | ______________ |
| (Your name printed) | (Your signature) |
| ______________ | ______________ |
| (Date) | (Subscriber number or Patient ID ) |
Requesting transfer of dental records to new dentist
From individual to doctor or medical institution
(NOTE: Some dentists or dental groups may require use of their own forms to request transfer of records. You can seek release of your records with your own letter, but they may respond with a form for you to fill out.)
After more than fifteen years in Lumbertown, I will be moving next month to Eumonia. I appreciate your assistance over the years. I am writing to request transfer of my dental records to a dentist near my new home.
I hereby authorize (name of dentist or dental group) to release to (name of new dentist or dental group) the full set of my dental records in your possession.
Please send the files to:
(New medical provider)
(Address)
(Phone number)
| _________________ | ___________________________ |
| (Your name printed) | (Your signature) |
| _____________________ | _______________________ |
| (Date) | (Subscriber number or Patient ID |
Filing power-of-attorney and legal and medical proxies with doctor
From individual to doctor or medical institution
Enclosed please find a certified copy of the following legal documents related to your patient, Jeremy Stein:
• Durable Power of Attorney
• Health Care Advance Directive
• Living Will
Please include these documents in your medical records for Jeremy Stein. I will be assisting Mr. Stein as necessary in making medical and other decisions.
Submission of power-of-attorney and health care proxy forms to nursing home
From individual to nursing home:
(NOTE: Consult with your attorney or legal advisor for advice on drawing up and filing power- of-attorney and other basic legal forms. Be aware that if you grant such powers to another you may be giving up some or all control over important financial, medical, and other matters.)
Regarding: Ben Adams
Account: 225 Rolling Stone Drive, Holliston, NY
Enclosed please find copies of a Durable Power of Attorney and Health Care Proxy granted by Ben Adams to me.
Please notate your files to indicate that I will be assuming responsibility for managing Mr. Adams’s financial affairs and that I have also been authorized to make any and all medical decisions on his behalf. I have included my day, night, and cell phone numbers below.
Please also note that in keeping with Mr. Adams’s express wishes, the Health Care Proxy includes a Do Not Resuscitate notice. We have discussed this matter with Mr. Adams and his attorney, and ask that his wishes in the event of a medical crisis be respected.
Granting permission to third party to discuss medical status
From individual to doctor or medical institution
I hereby grant permission to (name of doctor or medical facility) to verbally discuss with the below-named person or persons the following medical and billing information about me:
• Medical information, including my symptoms, diagnosis, medications, and treatment plan
• Lab, X-Ray, or test reports
• Scheduled appointments for assessment, treatment, or procedures
• Billing and payment information.
Such information may be disclosed to
(Name)
(Address)
(Telephone)
(Name)
(Address)
(Telephone)
This permission may be revoked by me at any time by written notice.
This permission is given by
(Your name)
(Your address)
(Your phone)
(Your Patient ID or Medical ID number)
Submission of power-of-attorney form and medical directive to doctor
From individual to doctor
(NOTE: Consult with your attorney or legal advisor for advice on drawing up and filing power-of-attorney and other basic legal forms. Be aware that if you grant such powers to another you may be giving up some or all control over important financial, medical, and other matters.)
Regarding: Ben Adams
Account: 225 Rolling Stone Drive, Holliston, NY
Enclosed please find copies of a Durable Power of Attorney and Health Care Proxy granted by Ben Adams to me.
In keeping with Mr. Adams’s wishes, the proxy includes a Do Not Resuscitate notice.
Further, the proxy gives express permission for any and all medical practitioners to disclose and discuss all medical conditions, procedures, and test results with me and to allow me to make informed decisions on behalf of Mr. Adams.
Please notate your files to indicate this Health Care Proxy as well as the Durable Power of Attorney that allows me to manage Mr. Adams’s financial affairs.
I have included my day, night, and cell phone numbers below.