Re:       Patient:

Policy or Plan Number:

Group Number:

Treatment Dates:

           Or 

The office for all patients (list about how many are active in your office)

Notification of Claim Negotiation With Third Party Repricing Company

Our organization has been contacted by _____________________ (Repricing Company). This company claims to represent ____________________ (Payor) in regards to the claim referenced above and can initiate binding agreements for payment of this claim.

This letter is to notify you that the following payment agreement has been reached:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

We have entered negotiations on a good faith basis and request payment by _____________ (Date). If payment is not received by this date, our organization demands immediate payment of the full charge. Failure to acknowledge this Notification of Claim Negotiation may be construed as a violation of state Unfair Claims Processing regulations and/or ERISA Claims Procedure regulations. Therefore, we request your prompt payment or reply.

Signed:            ____________________________________ (Negotiator)

Date:               __________________________________