Medical Reimbursement Letter [Sample]

Learn how to write a medical reimbursement letter. Use our sample medical reimbursement letter as a template for your reimbursement letter.

Medical Reimbursement Letter Sample

Claimant’s Name
Claimant’s Address
City, State, Zip Code


Insurance Administrator’s Name
Insurance Company’s Name
Insurance Company’s Address
City, State, Zip Code

Dear Name of Administrator:

This letter is to formally request reimbursement for medical expenses for policy NUMBER. I was visiting New York City on DATE where I fell and broke my wrist. 

I was treated at NAME OF HOSPITAL, and because I was from out-of-state, I needed to pay the bill in full. The amount was $3500 for x-rays, a bone specialist and one night in the hospital.

According to the terms of my policy, I contacted my primary healthcare physician within 24 hours of the accident. I have enclosed all the documents related to my treatment. 

I understand that I have a $500 deductible on my policy. I am requesting you to reimburse me $3000 in keeping with my health care coverage.

I can be reached at 555-123-4567 or at if you have any questions. Thank you for your quick attention to this.


Signature of Claimant
Printed Name of Claimant
List of Enclosures

related posts

  1. How to Write a Medical Claim Letter (with Sample)
  2. Writing a Simple Medical Insurance Grievance Letter
  3. How to Negotiate Medical Bills
  4. [Sample] Reimbursement Letter for Money
  5. Sample Medical Reimbursement Letter To Employer