Reimbursement Letter for Medical Expenses (Free Samples)
Use these sample reimbursement letters for medical expenses as templates for your formal reimbursement request letter.
Last updated on September 19th, 2021
Sample 1 - Reimbursement Letter for Medical Expenses
Name of Claimant
Address of Claimant
City, State, Zip Code
DATE
Name of Insurance Administrator
Name of Insurance Company
Insurance Company’s Address
City, State, Zip Code
Dear Name of Administrator:
This letter is to formally request reimbursement for medical expenses for policy NUMBER. I was visiting New York City on DATE where I fell and broke my wrist.
I was treated at NAME OF HOSPITAL, and because I was from out-of-state, I needed to pay the bill in full. The amount was $3500 for x-rays, a bone specialist and one night in the hospital.
According to the terms of my policy, I contacted my primary healthcare physician within 24 hours of the accident. I have enclosed all the documents related to my treatment.
I understand that I have a $500 deductible on my policy. I am requesting you to reimburse me $3000 in keeping with my health care coverage.
I can be reached at 555-123-4567 or at [email protected] if you have any questions. Thank you for your quick attention to this.
Sincerely,
Signature of Claimant
Printed Name of Claimant
List of Enclosures
Sample 2 - Reimbursement Letter for Medical Expenses
Name of Employee
Address of Employee
City, State, Zip Code
Name of Employer
Address of Employer
City, State, Zip Code
Date
Dear Name of Employer:
I am sending this letter to request reimbursement for the applicable medical expenses I have incurred due to pneumonia. I was admitted to the Name of Hospital, for five days.
I am enclosing all medical records pertaining to my treatment and hospitalization as well as the amount I am requesting for reimbursement for your perusal.
I hope to hear from you within 10 business days. If you need more information, you may reach me at 555 123 4567 or at [email protected] I will be happy to supply any more information you require.
I appreciate your time and support.
Sincerely,
Signature of Employee
Name of Employee
List of Enclosures
By Andre Bradley
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