Legal

Letter of Authorization (LOA)

Last updated: July 14, 2026

Template provided for convenience. Have your attorney review before relying on it.

This page summarizes the Letter of Authorization your practice signs electronically during onboarding. The LOA is the document that lets Revamend act with payers on your practice's behalf. Many payers require a copy before they will discuss claims with a third party, so we attach it to appeals and payer correspondence as needed. This summary is for convenience; the executed LOA is the binding document.

What the LOA authorizes

By signing the LOA, the practice authorizes Revamend to:

• Review the practice's remittance advice, explanation of benefits documents, and related claim records for the purpose of denial recovery.
• Prepare and submit appeals, reconsiderations, and corrected claims to payers on the practice's behalf, under the practice's own billing NPI and Tax ID.
• Act as an authorized submitter for those claims, including registering with payer provider portals as the practice's billing agent and, where the practice has separately granted user access, submitting and retrieving claim files through the practice's clearinghouse account.
• Communicate with payers by phone, portal, mail, and fax regarding those claims, including requesting claim status, denial rationale, and appeal outcomes.

What the LOA does not do

• It does not transfer or assign benefits. Payer payments continue to flow to the practice exactly as they do today. Revamend never receives payer funds.
• It does not make Revamend the provider of record or the billing provider on any claim. Claims are always filed under the practice's own NPI and Tax ID; Revamend acts only as the submitting agent. It is not an attorney-in-fact for any purpose beyond the claim work described above.
• It does not authorize Revamend to change clinical records, alter fees, or bind the practice to new payer contracts.

Revocation

The practice may revoke the LOA at any time by written notice to Revamend, including by email to support@revamend.com. Revocation is effective on receipt, except for actions already taken in reliance on the LOA. Revoking the LOA ends Revamend's ability to work claims with payers, so it normally accompanies termination of the engagement under the MSA.

How it is executed and used

An authorized signer for the practice, typically the owner dentist or office manager with signing authority, executes the LOA electronically during onboarding. The countersigned copy is delivered by email with your other onboarding documents. When a payer requires proof of authorization, we provide the LOA along with the specific claim details, and nothing more.

Questions about this document? Contact support@revamend.com.