Request for Records

To: [HMO or insurer]
From: [Member]
Member Number:

Ref: Your Denial Letter of [date]

Under ERISA, (29 USC 1132(c)(1)(B) and 29 CFR 2560.503-1(g)(1)(ii)) I have a right to copies of pertinent documents that [HMO or insurer] relied on in making its decision to deny my [type of claim] benefits.

I am hereby formally requesting copies of all such records used or referred to by, or influencing you in making that decision, including:

Please note that the ERISA sections cited authorize fines of up to $110 per day if the requested documents are not delivered within 30 days after the date of this request.

I shall rely upon the completeness of your response, and shall resist the production at a later date of any records predating your last denial letter which are not produced in response to this request.

Thank you for your assistance.