[DATE]

State Department of Insurance
[State]
123 Main Street
[any town], [state] [zip]

RE:

To Whom It May Concern:

I am a licensed doctor of chiropractic and have encountered significant difficulties with [Name of managed care organization, insurance company, or plan administrator] in connection with claims for services provided to my patient [s]. These difficulties include: include general description of the problem[s] , see ACA managed care website for examples of problems]. I believe the existing policies and procedures of [Name of managed care organization, insurance company, or plan administrator] may violate state law in that these policies and procedures have, in my view, seriously adversely affected my patient[s]. Therefore, I request more information on how I may file a more specific complaint outlining the facts and circumstances of my concern. I would also be available to discuss the matter in more detail with an agency investigator or appear before an administrative hearing. I look forward to you response and further guidance.

Sincerely,