Mr. Claims Adjuster
Found Another Way to Rip U Off Company
1234 Cheat U Lane
Anywhere, USA


Patient Name:
Claim Number:
Dates of Service:


Dear Mr. Claims Adjuster:

In response to your letter of ____________. You have denied the claims submitted as "non medical necessity". Mr. Patient is being treated for _____________. I am enclosing copies of my orthopedic and neurological examination and findings.

Mr. Patient diagnosis is consistent with the objective findings. Treatment consists of specific chiropractic manipulative treatments and physiotherapies of ______________, _____________, and _______________ to cure or relieve this patient from the effects of his condition. I am treating this patient on the basis of reduction of the symptomatology. Progress is anticipated in this patient's condition. Without the above referenced treatment, this patient could deteriorate, predisposing him to serious functional disabilities for which you may be held liable.

I am resubmitting these claims to you for prompt payment. If you have any further questions regarding Mr., Patient's care, please feel free to contact me directly.