Dorian Mayhew Rothschild 60 Arthur St. San Rafael, CA 94901 May 01, 2012 Rory T.

Davis Personnel Director The Negotiators Mediation Company 35 Palm Circle Dr. Corte Madera, CA 95422 Re: Beneficiary's Name: Dorian Mayhew Rothschild Medicare No: 123456779 Dear Rory T. Davis: The purpose of this letter is to request reconsideration of your initial decision regarding my claim to Hospital Insurance. The name and address of the health care provider and information regarding the services received are summarized below. Health Care Provider: Representative: Address: Saint Mary's Medical Care Services Gina Schaffenberger 123 Main St. Mill Valley, CA 94941

The date of admission or the date services began was on January 19, 2012. I received your initial decision on April 11, 2012. A copy of the initial determination is attached for your reference. Also, a copy of additional correspondence or notices regarding this claim is attached for your reference. The initial decision was made by: Name: Morgan Scheurman Address: 23 Dale Dr. San Anselmo, CA 94932

This request is made within 60 days of the date of receipt of the initial determination.

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I do not agree with the determination of this claim. Please reconsider this claim because I was over the age of 65 when I was in the hospital, having just celebrated my birthday two weeks prior to the stay. To support this request for reconsideration, I am enclosing Copy of my birth certificate and driver's license. You may contact me at the above address if you have any questions or need additional information. I can be contacted by phone at (415) 405-1578 or (415) 867-2856. Thank you for your assistance in this matter. Sincerely,

Dorian Mayhew Rothschild Beneficiary Enclosure

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