Model Letter to Insurance Company: Cooling Vest Reimbursement Request

Today’s date 
Plan Name
Plan Address
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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Stow, Ohio 44224
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