Sample Appeal Letter Template Page 2

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] t o a ddress a ny q uestions o r c oncerns y ou m ight h ave r egarding t his a ppeal.

Thank y ou v ery m uch f or y our t ime a nd c onsideration.

Sincerely,

[Physician’s n ame a nd c redentials]

Enclosures:

[ suggested e nclosures b elow – d elete w hat i s n ot a pplicable]

FDA A pproval L etter f or C OTELLIC

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Package I nsert f or C OTELLIC

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Safety i nformation f or C OTELLIC ( safety i nformation c an b e f ound a t

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)

BRAF V 600 M utation r eport

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Payer d enial l etter

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Clinical n otes/diagnostic p athology r eport

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CT/PET s cans s howing p rogressive d isease

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Journal a rticles, c linical p ractice g uidelines a nd o ther s upporting d ocumentation

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ACS/030915/0032

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Parent category: Letters