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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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     Indian Health Manual

Part 2, Chapter 3:  Manual Exhibit 2-3-G

Sample of Letter to Provide Follow-up on an Outstanding Purchase/Delivery Order Commitment Register

(Each Area should have a form letter to follow-up with their providers for outstanding purchase)


Name of Patient:

On __________________ you were sent Purchase/Delivery Order No. ________________ in the amount of $_____________, covering services provided on ______________ to _______________________ for ___________________________________.

To date, the completed claim has not been submitted for payment.

Please complete and return this form so that this account may be cleared from our records.  If we do not receive a response, the obligation for these services will be canceled.

If the form has been misplaced or the account has been covered by some other resource, please advise us so that appropriate action may be taken.

Sincerely yours, (Authorized Individual)

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