Your City, State, Zip Code
Health Plan Name
City, State, Zip Code
Dear Sir or Madam:
The purpose of this letter is to inform you of my problem with ___________ [ Briefly summarize the problem you are having. For example, "the denial of coverage for a treatment" or "a delayed payment of a claim" ]. My policy number is ______________.
My complaint concerns______________ [The reason for your complaint, followed by your explanation of what happened ]. To solve my problem, I would like _____________ [The specific action you want the plan to take].
I look forward to your reply and a resolution of my complaint.
[Include copies of all related records. Do not send originals.]