(ILAGAY DITO ANG PROVIDER NAME AT ADDRESS)

July 24, 2014

Vilma P. Bongalos
IMQ Midwife Clinic
217 Pasco Ave., Santolan Pasig City


Attn: Appeals Department


Re: Patients name
Policy ID/Group Number
Claim Number
Date of Service
Disputed Amount


Dear Sir/Madam:

Good day!

I am writing to appeal the request denial for Patients name. The reason on denial is the wrong
entry on date of admission wherein I put the admission date of the mother which is Ilagay ang
date instead of the birth date of her child which is on ilagay ang birthday ng bata.

I am requesting for the reconsideration of this claim.

I am looking forward for your kind consideration. Thank you.



Sincerely,


Vilma P. Bongalos R.M.
License no: Ilagay ang number
Contact no: 09991592430