Provider Grievance & Appeals Form
Use this form to formally dispute a denied invoice, repayment demand, termination decision, or any other Foundation action you believe was made in error. Submit this form and all supporting documentation to partners@paperflowerfoundation.org. The Foundation will acknowledge receipt within five (5) business days and issue a written decision within thirty (30) calendar days.
Provider Information
Full Legal Name
*
First Name
Last Name
Practice/Organization Name
*
Email Address
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone
Either
Nature of Grievance
What are you disputing?
Denied invoice
Repayment demand
Termination decision
Rate or billing code dispute
Prior authorization denial
Other
Date of the decision or action being disputed:
-
Month
-
Day
Year
Date
Invoice number or reference number (if applicable):
Amount in dispute (if applicable):
Statement of Dispute
Describe the basis for your grievance in your own words. Be specific. Include relevant dates, client initials, service types, and any prior communication with the Foundation about this matter.
What outcome are you requesting?
Supporting Documentation
What are you attaching?
Session notes or clinical documentation
Invoices in dispute
Prior authorization documentation
Prior correspondence with Foundation staff
Licensure or credential documentation
No documentation attached at this time
Other
File Upload
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of
Signature
By signing below I confirm that the information provided is accurate and complete to the best of my knowledge and that I am submitting this grievance in good faith.
Signature
Date
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Month
-
Day
Year
Date
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