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Patient Advocate Foundation
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Sample Physicians Letter

(Date)

(Name)
(Insurance Company Name)
(Address)
(City, State ZIP)

Re: (Patient's Name)
      (Type of Coverage)
      (Group number/Policy number)

Dear (Name of contact person at insurance company),

It is my understanding that (Patient's name) has received a denial for (name of procedure) because it is believed that the procedure is (state specific reason for the denial i.e., not medically necessary, experimental, etc.)

As you know, (patient's name) has been under my care since (date) for the treatment of (state disease). (Give a brief medical history emphasizing the most recent events that directly influence your decision to recommend the denied therapy.)

For this reason I am writing to provide you with information regarding (name of denied procedure). (Give a brief, yet specific description of the procedure and why you believe it should be approved.)

I have also included several journal articles supporting the use of (name of procedure) for (patient's name) (name of disease).

I ask that you reconsider your previous decision based on the information above. I believe therapy should begin on (date). Should you have any questions, please do not hesitate to call me at (phone number).

Sincerely,
(Doctor's Name)

Return to Step 3: Write The Appeal Letters