Cover sheet for an appeal packet
A one-page cover sheet that lists everything in your appeal packet and how you sent it, so nothing is missed and you can prove what arrived.
- Private: nothing leaves this tab
- A template, not legal advice
When to use this, and what it is not
When to use this. When you send an appeal or any request with more than a page or two of attachments. Put this on top, number the pages, and keep an identical copy.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the person this is addressed to]
Re: Cover sheet for an appeal packet Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
This packet is [What is in this packet] for the claim or request named above, sent to [Who it is addressed to].
It was sent by [How you are sending it] and contains [Total number of pages, including this one] pages. The deadline on my notice is [The appeal deadline on your notice].
Contents: [Everything you are enclosing, one per line, in order]
Please confirm in writing that you received this packet, and tell me the date you received it.
Sincerely, [Your name]
Before you send it
Use a method that gives you proof of the date it arrived: certified mail with a return receipt, a tracked courier, a fax confirmation page, a screenshot of a portal confirmation, or a signed receipt. Keep an identical copy of the whole packet.
What happens next
- Write the date you sent the packet and how you sent it in your call log and in My Plan.
- Put the proof of delivery with your copy of the packet as soon as you have it.
- Mark the date the plan must decide, using the deadline calculator or decision clock, and add it to My Plan.
- If you hear nothing by that date, write or call and say the date the plan received your packet.