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  • 12 28 07 Claim Authorization Letter

    Diunggah oleh

    OKTeaPartyPAC
    18 tayangan1 halaman
    VALVULOPLASTY, MITRAL VALVE, wrrn CARDIOPULMONARY BYPASS; WITII PROSTHETIC RING. If your insurance with PacifiCare has been terminated and any services are rendered, you are financially responsible.

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    Hak Cipta

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    VALVULOPLASTY, MITRAL VALVE, wrrn CARDIOPULMONARY BYPASS; WITII PROSTHETIC RING. If your insurance with PacifiCare has been terminated and any services are rendered, you are financially responsible.

    Hak Cipta:

    Attribution Non-Commercial (BY-NC)
    Unduh sebagai PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    18 tayangan1 halaman

    12 28 07 Claim Authorization Letter

    Diunggah oleh

    OKTeaPartyPAC
    VALVULOPLASTY, MITRAL VALVE, wrrn CARDIOPULMONARY BYPASS; WITII PROSTHETIC RING. If your insurance with PacifiCare has been terminated and any services are rendered, you are financially responsible.

    Hak Cipta:

    Attribution Non-Commercial (BY-NC)
    Unduh sebagai PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 1

    PacitiCare

    A UnitBdHealthcare Company

    Referral Authorization December 28, 2007

    Letter

    Daniel S. Sullivan 1338 E 43rd Ct. Tulsa, OK 74105

    Patient Name:

    Daniel S. Sullivan

    Authorization:

    ._'.._ .llatientl.D#:

    . 76_J0112=-_Ql_

    ~~

    ..:

    .._..

    07361-0115 . _CkvelaQd_CliDic. Found To Date


    1/12/2008

    Services VALVULOPLASTY, MITRAL VALVE, wrrn CARDIOPULMONARY BYPASS; WITII PROSTHETIC RING VALVULOPLASTY, MITRAL VALVE, WITII CARDIOPULMONARY BVPASS; wrrn PROSTHETIC RING I Dear Member:

    From Date 111112008

    Approved Units 1

    1/11/2008

    211112008

    :'-7

    0\~ii..- -tlrrtsL- ttO'5j?; ~~ (, t

    '2.

    4-h'd~

    The request for authorization, as shown above, has been approved. Coverage js based on your eligibility at time of service. If your insurance with PacifiCare has been terminated and any services are rendered, you are financially responsible. Previously approved services beyond the termination date are not covered . .If you have any questions regarding the limitations, co-payments, and/or benefits associated with these services, please contact PacifiCare Customer Service at 1-800-825.;.9355 between 8:00 a.m. and 6:00 p.m., Monday through Friday Sincerely.- . PacifiCare Medical Management

    cc:

    Cleveland Clinic Found Marc Gillinov

    800000101860000000009611221E

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