Printable Medical Forms
Appeal Medical Claim Denial Medical Form

Susie Queue

123 Main St.

Anytown, CA 95928

(555) 555-1212


August 14, 2021


ABC Insurance

345 Any Place.

Anytown, CA 95928


To whom it may concern,


I am writing to appeal the denial of medical claim number ___________ under policy number ___________________.



Here is the claim information:




Claim number:







The notice of denial gives no reason or explanation. Please reply with an explanation.


For your convenience, I’ve enclosed supporting documentation related to the claim. Please contact me if there is more information that I can provide to aid in this appeal.

I look forward your prompt reply.





Enclosures: supporting documentation

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