Preauthorization Letter Template
On this page you can download a template for a letter to send to your insurance company requesting preauthorization, which you should fill in with your information.
Instructions on how to complete the letter are on the first page of the document.
Below you can find the different paragraphs that you can copy into your letter under the "LEGAL EXPLANATION" section.
The legal explanations will be particularly useful in cases where your plan has a blanket exclusion or an exclusion of a specific procedure. The legal explanations can also be useful to appeal a denial of a preauthorization or claim request.
As a reminder, if you have a self-funded plan, you should write your employer or school for preauthorization. Find templates for self-funded plans here.
In addition to this letter, don't forget to attach a letter from your health care provider in support of your request.