DATE

Nationwide Insurance Enterprise
Medicare Operations
Attn: Hearing Department
P.O. Box 16781
Columbus, Ohio 43216-6781


Re: Patient: _______________________________
HIC#: ____________________________________
Injury #: __________________________________
ICN#: ____________________________________
DOS: ____________________________________


To Whom It May Concern:

I disagree with the review decision captioned above. On behalf of the patient and myself, I request a [in person or telephone] hearing to determine the medical necessity of these services.

I request a copy of the Medicare guidelines used to review this claim.


Sincerely,

[Doctor Name]

cc: Patient
Ohio Federal Legislators (optional)

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