Paid to old wrong address - appealing with W 9 form

Practice address
Phone# 123-456-7890

07/28/2010

Anthem BCBS
Attn: Provider Relations Dept.
PO Box 558
North Heaven, CT - 06473

Subject: To Update W-9 Form

Patient Name:
Health Insurer Identification Number:
Claim#
Call Reference Number: 27834824
Service Date: 03/15/2010

Dear Sir/Madam:

As per our discussion with customer service the representative said this claim paid to our old billing address Address, ST Petersburg, FL 33709-2141. The check information is as follows

Check# 2006557662
Processed on: 05/28/2010
Paid: $45.38

Now we are requesting you to update our new billing address and reverse the payment from this claim and pay according to the W-9 form attached herewith.

Thank you for reviewing and reversing this claim paid to our old billing address. If you require any additional information, please contact me at 407-123-4567 between the hours of 8:00 a.m-5:00 p.m.

Sincerely,


Your name
(Account Receivable – Reimbursement Specialist)