Right for Provider to appeal on behalf of patient

Right for Provider to appeal on behalf of patient
Patient Name (if child list child)*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Provider treating Patient*
I give consent for the provider listed above to file an appeal on my behalf with my insurance plan. This will be an appeal of the denial of prescription medication issued by my insuance carrier. I have read this consent or have had it read to me and it has been explained to my satisfaction.
Patient (Guardian Signature)

Clear
Should be Empty: