Get Form To Request For Review Of Cancellation, Rescission, Or Nonrenewal Of Plan Contract

This guide offers clear instructions on how to complete the Form to Request for Review of Cancellation, Rescission, or Nonrenewal of Plan Contract online. Following these steps will help ensure that your request is submitted accurately and effectively.

Follow the steps to successfully complete and submit your request.

1. Press the ‘Get Form’ button to access the form and open it in the online editor.
2. Enter the date in the space provided at the top of the form. Make sure to follow the format: month, day, year.
3. Clearly write the full name of the enrollee, subscriber, or group contract holder in the designated field. Ensure the spelling is correct and includes first, middle, and last names.
4. If the name of the subscriber differs from the enrollee in step 3, provide the subscriber's full name in the next field.
5. Indicate the name of the health plan in the designated field.
6. Input the subscriber or enrollee account or identification number. This number is important for identifying your specific plan.
7. If applicable, fill in the group identification number for your plan.
8. If you know the date you received the notice of cancellation, write that date in the format: month, day, year.
9. Attach copies of relevant documents, including the notice of cancellation sent by the plan, any correspondence related to the cancellation, rescission, or nonrenewal, and proof of payment for your last coverage period.
10. Indicate whether you know why the plan canceled, rescinded, or did not renew your coverage. Provide an explanation if you answered 'Yes.'
11. State why you believe the cancellation, rescission, or nonrenewal is incorrect by filling in the appropriate field.
12. Explain why you think the reasons provided for cancellation are wrong. Attach any supporting documents if available.
13. Indicate if the action prevents you or any enrollee covered under the policy from receiving medically necessary health care services, and provide an explanation if the answer is 'Yes.'
14. Clarify if the person named in the previous question has received any medical care since the cancellation and detail what services were received and the costs associated. Mark 'Yes' or 'No' accordingly.
15. Sign the form as the complainant, then indicate the date of your signature.
16. Once all fields are completed, you can save the changes, download, print, or share the form as necessary.

Take the next step and complete the Form to Request for Review of Cancellation, Rescission, or Nonrenewal of Plan Contract online today.