Dr. Name
Office address
City, State ZIP
(or preferably print on letterhead)

Date

Insurance company name
Insurance company address

re: John Doe, claim #1234546779 

Please consider this ADDITIONAL INFORMATION and reprocess the accompanying claim.

Existing conditions:

• 2        Missing; extracted 21 years ago.
• 3        Missing; extracted 23 years ago.
• 4        Recurrent M caries under failing MODL composite; less than 50% of supragingival tooth structure present.
• 5        New D caries
• 13      Deep D caries undermining B & L cusps; temporary DO filling; MO amalgam; less than 50% of supragingival tooth structure present.
• 15      Failing MODB composite; replaces DB cusp; has multiple fractures; less than 50% of supragingival tooth structure present.
• 18      Had Root Canal Treatment completed Oct 7, 2002; never been crowned; massive caries has left less than 50% of supragingival tooth structure present.
• 19      MO, B amalgams; recurrent D caries under deep DO composite undermines DB cusp; less than 50% of supragingival tooth structure present.
• 20      Recurrent D caries.
• 30      MO amalgam; recurrent D caries under DOBL composite replacing DB, DL cusps; less than 50% of supragingival tooth structure present.
• 31      New M caries.
• All     Moderate to Severe occlusal & incisal attrition from bruxism; causing dentin exposure, mobility, rapid deterioration of restorations.

Documents enclosed:

• Copy of original claim
• Copy of EOB
• Additional information (this document)

Sincerely,

Suzy Q
Insurance Coordinator