Part 2, Chapter 3: Manual Exhibits

Manual Exhibit 2-3-I

SAMPLE LETTER TO PROVIDER FOLLOW-UP ON AN OUTSTANDING PURCHASED/DELIVERY ORDER

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

Date:

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 by [enter a date], the obligation for these services will be canceled. Neither the patient or IHS will be responsible for these services if a response is received after [enter date].

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)