PLACE LETTERHEAD HERE AND REMOVE NOTE
Note: This form is intended as a sample form of the information that you as the surgeon should personally
discuss with the patient. Please review and modify to fit your actual practice. Give the patient a copy and
send this form to the hospital or surgery center as verification that you have obtained informed consent.
LETTER TO PATIENT REGARDING INFORMED CHOICE
NOT TO UNDERGO A RECOMMENDED TREATMENT/PROCEDURE
Patient Name
Patient Address
Dear (Patient Name):
On (Date), I prescribed (Test/Procedure). On (Date), (Name of PPO, IPA, HMO) did not consider the
test/procedure a covered benefit and denied payment authorization for same. On that basis, you have
informed me of your decision to forego the (Treatment/Procedure) I have prescribed. I expressed my
concerns regarding your decision during our discussion on (Date) about the potential ramifications of
your informed choice not to undergo the (Test/Procedure).
According to my best medical judgment, I recommend that you undergo the procedure regardless of the
denial of benefits by (Name of PPO, IPA, HMO). You have the right to appeal the decision of (Name of
PPO, IPA, HMO) should you choose to do so.
Should you wish to discuss this further, please do not hesitate to contact me.
Sincerely yours,
(Your Name)
Translated June 2014
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