Free appeal letter 31Free appeal letter 31
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Instructions:

This template is offered in response to a request from a Healthcare provider for a sample resource a healthcare provider
could use when responding to a request from a patient’s insurance company to provide a letter of medical necessity for
prescribing AstraZeneca medicines. Attachments to be included with the letter of medical necessity are original
claim form, copy of denial or explanation of benefits, and any other additional supporting documents. If you need
additional references, please contact our information center at 1-800-236-9933.
Use of the letter does not guarantee that the insurance company will provide reimbursement for AstraZeneca
medications, and is not intended to be a substitute for, or influence, the independent medical judgment of the
healthcare provider.
Sample Letter of Appeal
(Healthcare Provider Letterhead)
Date: [Date]
Payer Name: [Payer Name]
Payer Address: [Payer Address]
City, State, ZIP Code: [City, State, ZIP Code]
Payer Phone and Fax Number: