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Get External Review Request Form State Corporation Commission 216 A

Form 216-A 7/11 Page 1 State Corporation Commission Bureau of Insurance External Review P. O. Box 1157 Richmond VA 23218 Phone 1-877-310-6560 Fax 804 371-9915 Email externalreview scc.virginia.gov EXTERNAL REVIEW REQUEST FORM This External Review Request Form must be filed with the Virginia Bureau of Insurance within 120 DAYS after receipt from your health carrier of a denial of payment on a claim or request for coverage of a health care service.

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