Dear community member,

Thank you for using our online template to complete your health insurance appeal.

To learn more about the health insurance appeal process, please visit our website at https://transhealthproject.org/

Please note you are responsible for using this template to write your own appeal. THP cannot write, review, edit, or file the appeal on your behalf.

Furthermore, please take care to review any deadlines to file the appeal, and any subsequent appeal. It is your responsibility to file an appeal by the deadline. If you do not file the appeal(s) by the deadline, your appeal rights may be forfeit and you may lose any further chance to appeal the health insurance plan’s decision to deny you care.

*Please note that the above is not legal advice and the use of this template does not create an attorney-client relationship between you and THP/A4TE*

Please read these instructions before attempting to use the template:

• Text highlighted in yellow should be replaced by information relevant to your own particular situation.
• We have also included instructions & descriptions of the type of information you should be putting in each section, highlighted in green
• Please check that all text highlighted in yellow & green has been replaced/deleted before you send the appeal.
• You are free to add, edit, rearrange, or delete any portion of the appeal as you see fit.
• For the insurance company information header, please look at either your denial letter or your plan policy’s section on appealing denials. This is usually at the end of the policy. It should include an address and the name of the administrator that the appeal should be addressed to.
• If the denial letter and your plan policy give you different addresses, or you cannot find this information, please call your health plan or your HR department if you get your health insurance from your employer.
• Information for the member section should be found in your denial letter. You can get this information from your medical provider if you cannot find it.

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