I am a...
*
Provider
Policyholder
Authorized Representative
Name of individual submitting form
*
First Name
Last Name
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Authorized Representative Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized Representative Supporting Documentation
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Member ID
*
Please enter the first 9 digits of your policy.
Claim Number
*
Typically a 15 digit number.
Provider Tax ID
*
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Please describe the reason for your appeal.
*
Supporting Documentation
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of
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Preferred method of contact to facilitate correspondence (if necessary)
*
Email
Fax
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Email
*
Confirmation Email
example@example.com
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Fax Number
*
Please enter a valid fax number.
Format: (000) 000-0000.
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Response
Should be Empty: