![]() A copy of the award or other document showing the details of the payment is attached. I received an award or other payment to cover some or all of my attorney fees. Request Letter to HR for Health Insurance Card Sample Letter to HR Regarding Health Insurance Card. A copy of the agreement or order is attached. I received a lump-sum settlement or court-ordered payment. I have attached proof that I have paid these expenses (see the OUT-OF-POCKET EXPENSE Instructions to determine what proof is necessary). I have attached copies of the necessary documents to prove my case (see the OUT-OF-POCKET EXPENSE Instructions to determine what proof is necessary). Feel free to use 3 available alternatives typing, drawing, or capturing one. Click on the Sign icon and make an electronic signature. Indicate the date to the sample with the Date function. My retirement coverage has not been corrected to the _ retirement system.įor Social Security taxes (FICA) and CSRS retirement deductions paid, please provide the amount paid and the agency to which payment was made.įor reimbursement of interest paid on a CSRS (Offset) deposit, please demonstrate why your election of CSRS (Offset) does not fully compensate you for the error.įor all other expenses, please show (1) amount paid, (2) to whom paid, (3) why you believe the expense resulted from the coverage error, and (4) how that course of action would have corrected/mitigated the effect of the coverage error. Make sure the info you add to the Sample Letter Requesting Insurance Information is updated and correct. My retirement coverage was corrected to the _ retirement system on (date) _. I was incorrectly placed in the _ retirement system on (date) _. The name and address of my current or last Federal employer is _ My name is _, my SS# is _,Īnd my address is _. Re: Request for Reimbursement of Out-of-Pocket Expenses ![]() Benefits Officers Center Toggle submenuįederal Erroneous Retirement Coverage Corrections Act (FERCCA) Request for Reimbursement Sample Letter.Request a timely response and thank them for their time and assistance. Request that your employer adjust their insurance policy to include comprehensive treatment for the disease of obesity including bariatric surgery, FDA-approved anti-obesity medications, nutritional counseling, mental health and behavioral counseling.Ģ. In your last paragraph, discuss the following closing items:ġ. Patients with obesity deserve access to FDA-approved treatments in the same way we cover treatments for hypertension, diabetes, and other chronic diseases. Health outcomes are better for all diseases when treatment options are available, affordable, and accessible.ģ. ![]() Briefly discusses coverage options and self-pay discounts. Families Without Health Insurance : Template letter for patients and families who do not have health insurance. The number of people affected by obesity – click here to find state-specific information.Ģ. Outstanding Patient Account Balance Letter : Template letter to patients/families alerting them of an outstanding patient account balance. In your second paragraph, mention the following items:ġ. A short letter can accomplish just as much as a long one.) Elaborate on the number and cost of medications you are currently taking due to your obesity-related conditions. Explaining Out-of-Network Coverage Limitations. Tell the individual how obesity and its related conditions have affected you and your family. Share a brief medical history of your struggles with this disease. Discuss how you recently contacted your insurance provider to inquire about treatments for the disease of obesity and you were told that is not covered under their policy.Ģ. In your first paragraph, mention the following points:ġ.
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