lilucShicld
nf'l'exns

 

SulWCl'lhEl' Name SAMANTHA TRIMBLL

 

Oclnber 28, 2012

Deal SAMANTHA TRIMBLEs

Tlus lerrer is In respunse ru :1 requesr ofhensfils lur 
senice/procedure been as rnerlreully necessary as defined by your Care
Benefits bunkch nr- Summary Plan 

H):

Member Namc: HA TRIMBLE

Dale _197x

Dule' 

Tremmclu Acme

--

MILLWOUD HOSPITAL EXCEL 
Approved: 5

Service Prucerlure ADMISSION

Dale lzxpilzllion Dale Certified
man 2012 lam '2012 5

Please eunruer us al llre abuve lisled dalc rryuu require approval for
addilional days/nulls ofservice'proccdulcs than approved above.

Tu ensure benem coverage, you rnusr Contacl us followlng ueeurs:

- The plan or level Mare 15 change-i
The 

 

ls changed from that uorerl above
- Tue dale erservree rs changed or ernreellerl.

Appl'uval Health Care is run a ul'paymenv ofbeuefirs
Paymeru ofbeuerus ls lo several l'uerurs, illcludlng, bur nol limirerl lo, at Illc rune ru'
seniee, allowable for servrces, rnedrenl
uueumemnurur and erlrer lelnlm and exclusions ser l'unlr ru yullr l'ollcy Certificate
and/or Booklet and or Plan Deseripuen as well us llre preexiSling condition walling
period, lfany, Customer at Illc phone number on llre back ul'yeur insurance In

PO Box <Page 2 
Ucluhel' 28V 2012
SAMANTHA TRIMBLE
8449310"

card questions aboul benefits. You [brainy outeofepncket cosh, lncludlng, um
um coinsurancc. cupuyuteutu deductibles and/or 

Please note |}1al ifyuu are scmces through a provider (a
provulel whom Blue and Blue of'lexas does not have a common/agreement), you may
be Iespousiblc ret uuteelipeeket cns|s fm tut: sewice, Th: provider Is not obligaled to accept
Blue Cross and Blue slueld nfTems allowable xmmunt as payment lull. A 
paruclpuung )VI'UVidcl may also charge you for any billed ovet [he ammuu allowed for payment,
lryuu need help finding a call Customer at Ihc number listed
on your member idenuficullnn MM.

1 lte decision to (he proposed l'cmalns between you and your health care
provide>>. Cmslagu. benefit and payment ue 'mns do not ueuuneut 

   

stueetety.

Blue and Blue Shield oFTcxas
":3th Can: Department
Phone Number. 7883-3984107!)

Fax Number: [78777361-7646



 

HOSPITAL EXCFL CENTER
101] NORTH COOPER STREET
ARLINGTON TX 760] [70000