Fax to: 800-704-7002
Attn: Claims/Pre-existing
Condition Review
Or mail to: Claims/Pre-existing
Condition Review
PO Box 2344
Brea, CA 92822-2344
REVIEW REQUEST FORM
NO COVER SHEET
NECESSARY
No. of Pages
MEMBER INFORMATION
Policy Number: Pet Name:
Member Name: Phone:
TYPE OF REQUEST
q I would like to request a review of a noted pre-existing condition.
We recommend you submit your review requests when filing a claim. Your pet must be deemed cured and have
remained treatment-free for a period of at least six months in order to be eligible for review. Chronic conditions
or other conditions that cannot be cured are not eligible for coverage. Below, please indicate the condition(s) you
would like to have reviewed.
Please provide a copy of all medical records for the past 12 months prior to the date of your request.
These records may be handwritten or computer-generated, but must include the results of the physical
exams performed, detailed doctor’s notes and laboratory results.
q I would like to request a review of claim number(s) because:
(Claim number is listed on your Explanation of Benefits)
q My claim was denied for denial code . (Denial codes are listed on your Explanation of Benefits)
Please provide a copy of all medical records for the past 12 months prior to the date of your
request. These records may be handwritten or computer-generated, but must include the
results of the physical exams performed, detailed doctor’s notes and laboratory results.
q My pet has a dierent diagnosis from that listed on the original claim form.
Please provide supporting documentation from the attending veterinarian(s) from the date
your pet was first diagnosed to the present. Documentation may include handwritten or
computer-generated medical records, along with any supporting laboratory results.
q Additional benefits may be available.
Please provide supporting documentation from the attending veterinarian(s) from the first
date of treatment through the present. Documentation may include handwritten or computer-
generated medical records, along with any supporting laboratory reports and biopsy results (if
applicable).
Comments:
Underwritten by Veterinary Pet Insurance Company (CA), Columbus, OH, an A.M. Best A+ rated company (2017); National Casualty Company (all other states), Columbus, OH,
an A.M. Best A+ rated company (2017). Agency of Record: DVM Insurance Agency. Nationwide, the Nationwide N and Eagle, and Nationwide is on your side are service marks
of Nationwide Mutual Insurance Company. ©2018 Nationwide. 18RET5635
Diagnosis Name
Pre-Existing Condition Code
(codes are listed on the Declarations Page of your policy)
OR
