Get Request For Administrative Review - Fidelis Care - Fideliscare

Filing a Request For Administrative Review with Fidelis Care is an important process for ensuring that you receive the support and assistance you need with your claims. This guide provides clear, step-by-step instructions to help you fill out the form online with confidence.

Follow the steps to complete your request effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the payee’s representative in the designated field at the top of the form. This is the person who will confirm the details outlined in the affidavit.
3. In the next section, write the name of the payee who has not received the check. Ensure that you spell the name accurately to avoid any delays.
4. Fill in the Check No. in the corresponding field. This number can be found on the check that has been lost, stolen, or destroyed.
5. Write the amount of the check in the appropriate section. Double-check the figures to ensure that they are correct.
6. Indicate the date on which the check was lost, destroyed, or stolen. This information is crucial for processing your request.
7. Confirm that neither the payee nor anyone under their authority has attempted to negotiate the check by marking the relevant acknowledgment.
8. Read the final statement regarding the agreement to complete an affidavit of forgery if the check is negotiated. Ensure your understanding before proceeding.
9. Sign the form as the payee's representative, including your name and title in the designated areas below the signature line.
10. Have the affidavit acknowledged by a notary public. This step is essential for legal verification and should be completed in front of a notary.
11. After completing the form, save your changes, then download, print, or share the document as needed to submit your request.

Ensure to complete your Request For Administrative Review online today to facilitate a timely resolution.