Sample Medical Insurance Warning Letter Template
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1
2
3<Date>
<Name>
<Address>
<PMI#>
[Warning
Letter]
Dear <Member Name>:
UCare reviews the way our members use health care services. Using many different health care
providers can be harmful to your health. You will get the greatest benefit from your health
services if you use one pharmacy, one primary doctor/clinic, and one emergency room whenever
possible.
Emergency room visits should only be used for actual emergencies. A life-threatening health
problem is an example of an emergency. Talk to your primary doctor if you are not sure what
life-threatening health problems are [(or call Health Connection, the 24-hour nurse line at
1-800-942-7858 (toll free) for advice at any time day or
night).]
We have reviewed the health services you received during the last
<#>
months. Here is a list of
services you used:
[<#>
pharmacies.
<#>
clinics and
<#>
of prescriptions prescribed by
<#>
doctors.
<#>
emergency room visits. Emergency rooms are to be used for actual health emergencies and
not for health problems that could have been cared for at a clinic, urgent care or dentist
office.]
[Revise according to the circumstances of the case.]
We want to make sure our members are receiving the best and most cost effective care. We will
at times review your health care services. If you continue to use health care services in this way
or if you do not reduce the number of providers you use, you may be placed in the Restricted
Recipient Program. We will notify you in writing if you are placed in this program.
Enclosed is information on where to go for care. It is a helpful guideline for you to use and gives
examples of when it is appropriate to use your doctor’s office, convenience care, urgent care, and
emergency room.
PMAP MnCare SNBC_071212_1 DHS Approved (07262012)
U4898 (07/12)
500 Stinson Blvd. NE Minneapolis MN 55413-2615
P .O. Box 52 Minneapolis MN 55440-0052
612-676-6500
1-866-457-7144
TTY : 1-800-688-2534
Fax: 612-676-6501
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