Note to your doctor's office
A short, courteous note to your doctor's office that says exactly what you need for your appeal, whether that is a letter, records, a call to the plan or a billing check, and by what date.
- Private: nothing leaves this tab
- A template, not legal advice
When to use this, and what it is not
When to use this. Use this when you are appealing and need your clinician's help. Attach the denial letter. A busy office responds best to a specific request with a date, so fill in the date you need things by and the appeal date, and tick only the optional paragraphs you need.
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 of your doctor or the clinic's office manager]
Re: Note to your doctor's office Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
Dear [Who at the office this is for]:
Thank you for caring for me. [Name of the health plan] denied [The care or drug that was denied] on [Date on the denial notice], claim [Claim or reference number]. I am appealing, and your office can help more than anyone. I know your time is limited, so here is exactly what would help and by when.
What I am asking for:
1. A letter from [Your doctor's name] explaining why this care is medically necessary for me, written from my chart. A template for the letter is available if it saves you time, and you are welcome to change it or write your own. 2. A copy of my records for this care, including visit notes, test results and referral letters. 3. If the plan offers it, a phone call from [Your doctor's name] to the plan's reviewing doctor about this denial.
I need these by [The date you need things by]. My appeal is due by [The date your appeal is due], and I want to be sure your letter arrives well before then.
I have enclosed the denial letter. It has the plan's reason for the denial and the number to call.
Please call me at [A phone number where the office can reach you] if you need anything from me, or if your office cannot do this. If you cannot, please tell me soon so that I can look for another way. Thank you for your help.
Enclosures: 1. Copy of the denial letter 2. Any template letter you want the office to use
Sincerely, [Your name]
Before you send it
Hand it to the front desk, or send it through the patient portal, with the denial letter. If you hand it in, ask the person for the date and their name and write them down. If you use the portal, take a screenshot that shows the date. If you fax it, keep the confirmation page. Follow up by phone about three days later and write down who you spoke to.
What to enclose
- Copy of the denial letter
- Any template letter you want the office to use
What happens next
- You: hand in or send the note with the denial letter at least two weeks before your appeal is due. Ask who will handle the request and write down the name and date.
- Office: completes the letter, the records and any call by the date you gave. Ask when you can expect each, and note the answer.
- You: if the date passes, phone the office, stay courteous and ask for a new date. Your appeal deadline keeps running. Your appeal deadline depends on your coverage and is printed on your denial notice. For most job-based and individual plans it is at least 180 days after you receive the notice. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different deadlines, often shorter, and they are on your notice. Check the date on your notice, which controls.
- You: when the letter arrives, read it. If it is missing something, such as the diagnosis or what happens without the care, ask the office to add it before you send it to the plan.