Tell us about your denial

Start with the basic facts from your denial letter.

First Name

Last Name

What was denied?

Insurance Company

Plan Name (optional)

Member / Policy ID (optional)

Claim Number (optional)

Date of Denial

Appeal Deadline (optional)

What reason did the insurer give for the denial? Copy this word-for-word from your denial letter if possible — this is the most important field on the entire form.

What type of denial did you receive?

Medical Procedure Surgery, diagnostic test, or specialized treatment.

Prescription Medication Specialty drugs, pharmacy coverage, or refills.

Referral / Out-of-Network Specialist visits or out-of-network provider care.

Other / Miscellaneous Anything else not listed above.

Your condition & treatment history

This section tells us what you're dealing with and what you've already tried. Be as specific as possible.

What condition is this medication or treatment for?

Diagnosis Code (optional)

Found on your denial letter or medical records.

How long have you had this condition?

How severe is it?

Mild Moderate Severe

What other medications or treatments have you already tried for this condition? For each one, include why you stopped — didn't work, side effects, doctor switched you, etc. This is critical information.

Did your doctor document these treatment failures in your medical records?

Yes No Not sure

Has your doctor written a Letter of Medical Necessity?

Yes No I'll request one

Your doctor & plan details

A few questions about your physician and how your plan handled the denial.

Who prescribed this? (name and specialty)

Is your doctor willing to support this appeal if needed?

Yes No Not sure

What reason did your doctor give for prescribing this? (optional)

Do you have a copy of your Summary Plan Description or plan documents?

Yes No I'll request it

What is the stated basis for the denial?

Not medically necessary Plan exclusion Other / Not sure

Have you been denied for this same thing before?

Yes No

The human side of your case

This is where your story goes. Be honest and specific — the more real this feels, the stronger your letter will be.

How is your condition affecting your daily life right now?

What happens to your health if this is not approved?

Are there any urgent or time-sensitive circumstances? (optional) e.g. upcoming surgery, rapidly worsening condition, running out of medication

Upload your denial letter (optional but recommended)

Uploading it lets us extract policy IDs and denial codes automatically for a more accurate letter.

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PDF, JPG, or PNG — max 10 MB

Your Email Address

Your letter will be delivered instantly to this address and available for download.