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Get Medical Mutual L6854 2012-2024

R INFORMATION Last name of patient First name of patient MI Policy ID # Date of birth (MM/DD/YYYY) Name of authorized representative pursuing appeal, if different from above (See instructions, page 2) Relationship to patient Mailing address City State Daytime telephone number Evening telephone number ZIP Code TYPE OF REQUEST Please check one  Benefit/coverage issue  Prescription drug  Dental service  Vision service  Medical necessity denial – post-service (service.

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