Explanation of Benefits (EOB) Request Letter

Build a letter to request the missing or unclear Explanation of Benefits for your claim and specify how you want it delivered.

Request the EOB for your claim

All fields are optional. Include enough claim details so the insurer can locate the EOB quickly.

Status message placeholder

Policyholder Name

Address

Insurance Company

Policy Number

Member ID

Patient Name

Claim Number

Date(s) of Service

Provider / Facility

What’s Missing / Unclear

Requested Delivery Method

Generates a clear EOB request letter with space for missing details.

🔒 MANDATORY CODEX SAFETY FOOTER (INCLUDE VERBATIM)

Do not modify global layout, header, footer, ads, analytics, or shared components
Do not import @/components/ui/select or any unverified shadcn components
Use native HTML inputs only
Row add/remove buttons must be plain <button>
No date math, no parsing, no calculations
PDF builders must return Promise<Uint8Array>
Always create Blobs using bytesToPdfBlob(bytes) from lib/pdf/bytes.ts
Never include null in React-PDF style arrays
No refactors
Tool may only break itself

Processing stays in your browser. PDFs generate locally—no uploads or accounts.
Downloads use a secure PDF blob helper (no raw array buffers or workers required).
Review details before sending; nothing here is legal advice or a substitute for local forms.