Premera Member Appeal Form (Patient Part)

Member Appeal Form

To submit an appeal, complete this form and send to the address on page 2.

Section A. – Member information
Date of birth: (MM/DD/YY)*

MonthDayYear
Date
First Name*
Last Name*
ID number: Prefix (3 characters)*
ID number: *
ID number: Suffix (2 characters)*
Group/Policy Number*
Address*

Address

Street Address Line 2

City/StateState / Province

Postal / Zip Code
City/State*
ZIP code*
Phone number*
Format: (000) 000-0000.
If you’re appealing on the member’s behalf, complete section B. If you’re the member, continue to section C.

Yes, I am the legal guardian.Yes, I have Power of Attorney.
No, I’m not the legal guardian and I don’t have Power of Attorney.
If no, the member listed in section A must complete the following appeal authorization section. Appeal Authorization:
First Name
Last Name
Phone number
Format: (000) 000-0000.
Address

Address

Street Address Line 2

City/StateState / Province

ZIP code
Release of Healthcare Information and Records By signing this form, I understand and agree to the following: Premera Blue Cross, or any of its affiliates (“the Company”), may disclose my health records to the authorized representative listed on this form. I understand that the healthcare information may include my benefit, claim, diagnosis, and treatment records including information about the following sensitive healthcare diagnosis and treatment (you may cross off items you prefer not to share
- Alcohol and/or chemical dependency
- Sexually Transmitted Diseases (including HIV/AIDS)
- Genetic information
- Reproductive health (including abortion)
- Gender-affirming care, gender dysphoria, domestic violence, and behavioral health
You can change your mind and withdraw this release at any time by informing the Company in writing at the address listed on page 2. The Company will make sure the change goes into effect within 5 business days after receiving your withdrawal request and will not be liable for any information released before your change goes into effect. This release is voluntary. We won’t condition your health plan enrollment, eligibility for benefits, or claims payment on giving this release. This release lasts 24 months from the signature date or until the appeal process is complete, whichever is earlier.
Date*

MonthDayYear
Date
Member Signature*

Clear

Section E. – Sign and Send
Member Signature*

Clear
Date*

MonthDayYear
Date
Authorized person signature (parent, legal guardian, Power of Attorney)*

Clear
Date*

MonthDayYear
Date
Printed Name*
Email*
example@example.com
By checking this box, you agree to receive your appeal decisionand other correspondence related to your appeal via the email addressnoted in Section E. You can change your mind at any time and/orrequest a paper copy of any notice by contacting us at the addresslisted on this form.
Should be Empty:

Member Appeal Form

Section E. – Sign and Send