Connecticut Sample Letter for List of Medical Expenses [Your Name] [Your Address] [City, State, Zip Code] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, Zip Code] Subject: List of Medical Expenses — Insurance Claim [or Personal Records] Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request a detailed list of medical expenses incurred for the purpose of filing an insurance claim [or personal records]. As a patient at your esteemed medical facility in Connecticut, I would appreciate it if you could provide me with a comprehensive breakdown of all the charges related to my recent medical treatment. As per my understanding of insurance claim protocols, it is crucial to have an itemized statement of all the medical services received along with their respective costs. This information will enable me to accurately submit the necessary documentation to my insurance provider [or maintain my personal records]. Below is a list of details that I kindly request you to include in the provided document: 1. Name of Medical Service: Please specify the name of each service or procedure performed during my treatment. 2. CPT (Current Procedural Terminology) or HOPES (Healthcare Common Procedure Coding System) Codes: Please provide the specific codes associated with each service. 3. Date(s) of Service: Clearly mention the date(s) when each service was rendered. 4. Description: Provide a concise description of the service performed, including any additional relevant information. 5. Quantity: Specify the number of times each service was provided, if applicable. 6. Unit Price: Indicate the cost of each individual service. 7. Total Cost: Sum up the total cost of all services provided during my treatment. I sincerely request that you provide this information in a format that is easily readable and preferably in an electronic document (PDF or Excel). If there are any specific forms required by your facility, kindly include them with the statement or provide guidance on how to acquire them. I understand that preparing this list may require some time and effort. Therefore, please let me know if there are any fees associated with the preparation of this statement. If required, kindly inform me of the payment process or any alternative means of obtaining this information. As it is crucial for me to submit the required documents to my insurance provider [or maintain comprehensive personal records], I kindly request your prompt response. I will be more than willing to provide any additional information or documentation necessary to expedite this process. Thank you in advance for your cooperation. Your assistance in providing this detailed list of medical expenses is greatly appreciated. If you have any questions or require further clarification, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address]. Looking forward to your prompt response. Sincerely, [Your Name]
Connecticut Sample Letter for List of Medical Expenses
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