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Get WA HCA 20-0161 2022-2023

Copy of your form for your records. Use this appeal form if you are a current or former employee (or their dependent). Follow the instructions under the heading that describes your situation. If you disagree with a decision made by the employer and you are requesting the employer's review about premium surcharges or eligibility for or enrollment in: A premium payment plan Medical coverage Dental coverage Vision coverage Life insurance Accidental death and dismemberment.

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