Dac Message 5674

<b>Medical Lack of Insurance</b><br><br>

You must submit either the written denial from your insurance carrier or the explanation-of-benefits statement for the amount(s) which they have covered. <br><br>

If you are NOT covered by any health/medical insurance, please sign and date the Statement of Insurance form that you will receive and return it to us with the following information:<br><br>

<ul>
<li>Name, address, and telephone number of provider(s) of service(s).</li>
<li>Itemized bills/receipts (NOT STATEMENTS) from the provider(s) of service(s).</li>
<li>Date of loss of PRESCRIPTION MEDICATION.</li>
<li>Receipts from the pharmacy showing the replacement cost of the medication.</li>
<li>Written verification from the pharmacy showing the prescription was filled prior to the disaster.</li>
<li>Written verification from your physician stating that your condition requires the medication.</li>
</ul>