Model Letter to Insurance Company: Cooling Vest Reimbursement Request

Today’s date

Plan Name

Plan Address

To whom it may concern:

Please refund to me $_________ for the purchase of a cooling garment (vest) (system) (HCPCS code A0270) that was prescribed by my physician. A copy of the prescription is enclosed.

A copy of my receipt is also enclosed.

Please send payment to:

Mr/Ms _________________________

_______________________________

My phone number is ___________________

My insurance policy, Medicare/Medicaid number(s) are:

_________________________________________________

Very Truly Yours,

_________________________________________________

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