Employee:
Employee ID# :
Claimant Name:
Claimant Acct:
Service Dates:
Total Billed:
Claim:
Dear Provider:
We have recently received charges for the above claimant
as shown above.
In order to consider these charges for payment, we must
have the following information requested below:
1. Was this condition work-related or military service related?
______________________________________________
______________________________________________
2. In your opinion, what is the etiology of this condition?
______________________________________________
_______________________________________________
_______________________________________________
**********************************************************
* *
* Doctor's Signature _______________ Date______________ *
* *
**********************************************************
Your cooperation in providing us with this information is
greatly appreciated.
Sincerely,
Claims Department
