Sample Letter Templates

These sample letter templates are provided as a reference for practices developing their own materials and may be adapted to local needs. You should consult an attorney who is knowledgeable about the laws of the jurisdiction in which you practice before creating or using any legal documents. ​  

​Disclaimer: These sample documents do not represent AAP policy or guidelines. They are provided only as a reference for practices developing their own documentation.   

Medical Necessity Letter to Payers: Physician’s Letter of Medical Necessity for Home Health Care per EPSDT (Early and Periodic Screening, Diagnostic and Treatment) mandates. 

Payment-Related Letters to Patients/Families 

Notification of Practice’s Financial Policies: ​Template letter notifying patients/families with insurance that includes high out-of-pocket expenses (deductibles and co-pays) about the practice’s financial policies.  

Outstanding Patient Account Balance Letter​​: Template letter to patients/families alerting them of an outstanding patient account balance.   

Families Without Health Insurance: Template letter for patients and families who do not have health insurance. Briefly discusses coverage options and self-pay discounts.  

Response to Bill Questions​​: Template letter to update a patient/family after they have questioned a bill. 

Practice Dropping Insurance Plan​: Template letter to patients/families advising them that their practice will no longer accept a specific insurance plan or the pediatrician is no longer an in-network provider.    

Pending Application for Medicaid Coverage​​: Template letter to patients/families informing them of practice’s procedures for patients with pending Medicaid applications.  

Procedural Letters to Patients/Families 

Welcome New Patient Letter : Template letter to patients/families welcoming them to the practice.  

Primary Care Discharge Letter : ​Template letter from a primary care pediatrician regarding their inability to provide continued medical care to a child/family.   

Subspecialist Discharge Letter : Template letter from a subspecialist regarding their inability to provide continued medical care to a child/family.  

​Closing a Practice : Template letter notifying families when closing a practice (could include retirement), including the date of office closure and guidance on transferring records to another pediatrician. 

Retiring from Practice: Template letter notifying families when retiring from a practice, including date of retirement and guidance on transferring records to another pediatrician.