Funding and access
Letter and appeal templates
Copy, print or save the appendices from the funding guide as a PDF. Your care team and plan can help you adapt them to your request.
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Appendix 1. Clinician LMN guidance and template
Guidance and a letter outline to prepare with your clinician.
Unlock free templatesAppendix 2. Internal appeal letter template
A starting point for asking your health plan to reconsider a decision.
Unlock free templatesAppendix 3. Independent external review request template
A request outline for an independent review of a coverage decision.
Unlock free templatesAppendix 4. Medicaid EPSDT and fair-hearing templates
Request and hearing outlines to adapt with your Medicaid team.
Unlock free templatesAppendix 5. Records and policy request template
A letter to request the records and policies behind a coverage decision.
Unlock free templatesAppendix 6. Miscellaneous-code request checklist
A checklist for assembling a miscellaneous-code funding request.
Unlock free templatesGeneral information, not legal or insurance advice. Coverage and funding are not guaranteed. Program rules and product arrangements can change. Confirm the current rules with the plan or program before spending money. Last updated: October 16, 2026.