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ERISA - Sample Appeals Letters

Reviewed and updated on 11/7/2015

They can also be downloaded directly, by right-clicking on the link with your mouse and and selecting "save as" These forms are meant to be a GUIDE; these aren't official forms/letters.

Appeal for Billing Problems

Appeal for Medical Necessity

Appeal for Non-Covered Services

Appeal for Non-Formulary Drug

Grievance Letter Against a Professional

How to write a cover letter - Sample Grievance Letter attached

Request for Records - Used to Determine Coverage When an Appeal was denied.

Sample Letter - Failure to Respond to Request for Information