Immunization Coverage Complaint

Sample Letter

Today’s Date:

Member Name:

Member Date of Birth:

Member Insurance ID:

Dear Insurance Company,


Immunization Name(s):

Medically indicated Immunizations and Preventive services must be covered by insurance 100% according to rules and regulations set forth by the Affordable Care Act. My doctor states I need the above immunization course(s). If you do not confirm in writing within five days that the above immunization will be covered in full according to ACA guidelines, I will submit a complaint with the NY State Dept. of Insurance.

Optional:. Per the US CDC (Center for Disease Control), for Men who have sex with Men, these immunizations include Hepatitis A, B, HPV, Meningitis, and others:



If this issue it not addressed within 5 business days, I will submit a letter of complaint to the New York State Department of Insurance within 10 business days from the date of this letter.  


Patient name

Patient address

Patient phone number