• Ophthalmic Mutual Insurance Company (OMIC)

    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)