Rejection Request Letter
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REFUND REQUEST REJECTION LETTER Note: n n n If you are a contracted provider, use the entire second sentence (yellow + green) If you are NOT a contracted provider, use only the yellow portion of the second sentence Remove the highlighting and insert the appropriate info in brackets before sending J Current Date Attn: Director of Claims Insurance Policy 1 Carrier Insurance Policy 1 Address Re: Patient: Patient Name Policy: Insurance Policy 1 Number Insured: Responsible Party Name Dates of Service: First Service Date - Last Service Date Amount: Total Charges Dear Director of Claims, We are in receipt of a refund request regarding the above referenced claim..
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