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Get Mhs Claim Form

APPEAL FORM Mail completed form to Managed Health Services. Appeals Department. P. O. Box 3000. Farmington MO 63640-3800 Name/Address of Person Submitting Appeal Date this form is being sent Provider Name MHS Provider Number Claim Control Number Date s of Service Member Name Reason for appeal Other insurance payment Explanation of Benefits EOB Explanation of Processing EOP must be attached Incorrect payment or other please explain in detail below.

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