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This guide provides you with a comprehensive overview of how to fill out the Images For Who Is document online. By following these steps, you will ensure that your form is completed accurately and efficiently.

Follow the steps to accurately complete the form online.

1. Press the ‘Get Form’ button to obtain the form and access it in the online editor.
2. Begin by filling out the member's name in the designated field.
3. Enter the member ID number in the corresponding box.
4. Fill in the patient's name as it appears on relevant documents.
5. Provide the patient's date of birth in the format of MM/DD/YYYY.
6. Complete the mailing address, ensuring to include street, city, state, and zip code.
7. Input the phone number where the member can be reached.
8. If applicable, note the provider’s name and the dates of service related to the appeal.
9. Clearly state what decision you are appealing in the provided space.
10. Detail your explanation for why you believe the service should be covered. If necessary, attach additional sheets.
11. Attach any supporting documentation, such as medical records or letters, to strengthen your appeal.
12. Have the member or an authorized representative sign and date the form.
13. Once you have completed all fields, you can save changes, download, print, or share the form as needed.

Complete your form online today to ensure your appeal is submitted timely.