Letter Template for Insurance Inquiries
Reproduce the letter found below and send it to your insurance carrier(s). The ( ) indicate information you need to supply and the [ ] indicate additional information or clarification.

Download a Microsoft® Word® version of this template

(Date)
(Insurance Company)
(Street or Mailing Address)
(City, State ZIP)

Re: Predetermination of benefits for (patient's name)
ID number: (your ID number)

Group and/or Group number: (your group name and/or number if available)
[Find your group and/or ID number and mailing address on your insurance card. This information allows the insurance carrier to locate your group or individual policy and determine benefits.]

Dear (Insurance Company),

I am considering infertility services with Dr. (physician's name and address). My partner and I are seeking infertility services due to (explain your situation, e.g., blocked fallopian tubes, male factor, previous sterilization, unexplained infertility, etc).

Please provide me with a written response to each question below.

1. What infertility benefits do I have under my current insurance coverage?

2. Do I have diagnostic infertility coverage allowing the physician to find the cause of my infertility problem?

3. Do I have infertility treatment coverage allowing the physician to perform procedures that will help me become pregnant such as intrauterine insemination or in vitro fertilization?

4. If yes, is there a treatment limit of any kind (dollars or number of attempts)? If attempts, define an attempt.

5. Do I need a referral to visit Dr. (physician's name)?

6. If you require a referral, how often will I need to update the referral?

I would appreciate a response as soon as possible as I will be seeing my physician in the near future. Thank you.

Sincerely,

(Your name)

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