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Get VA DHRM Health Benefits Program Appeal Form 2011

R wishes to appoint someone to represent them during the appeals process. NAME OF AUTHORIZED REPRESENTATIVE: _______________________________ NOTE: For appeals related to medical or mental health and substance abuse claims, you must submit a completed HIPAA Authorization Form to DHRM before the appeal can be processed. The form is available on the DHRM Website at www.dhrm.virginia.gov under Appeals or from your Benefits Administrator. Revised 5/2011 Health Benefits Plan for State and Local Emp.

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