Need Sample PCP Letter

My next step is to get the approval letter from my PCP to be presented with the paperwork to the insurance co. I have BCBS-HMO and would like a sample of what to include in my letter for her to sign. If you have BCBS-HMO and have a sample of what should be included in the PCP's medically necessary letter for approval, please email me. Thank you so much.

I have Aetna but would be glad to send you a copy of the letter my PCP wrote for me. Just let me know. ~Bonnie