Explanation Of Benefits {SDF-6}

SDF-6 Explanation of Benefits Claimant Name: SDTF Claim No.: Date of Accident: Employer: Provider I.D.: Provider Name: Provider Address: Insurer Name: Insurer Code No.: Insurer FEIN: Diagnosis: 1) 2) 3) 4) Service Dates: From To Procedure Diag Codes Description Code Provider Charges Recommended EOB Reduction Payment Code Total Charged: Reductions: ********************* Total Payable: ********************* Explanation of Benefits: Form DFS-F1-SDF-6 (Rev. 1/31/2008) American LegalNet, Inc. www.FormsWorkflow.com