Follow the steps to complete your appeal request.

1. Click ‘Get Form’ button to obtain the form and open it in an editable format.
2. Begin by filling in the enrollee’s information. Provide the enrollee’s name, date of birth, and home address, including the city, state, and ZIP code.
3. Enter the primary phone number and cell phone number of the enrollee. If there is an alternate phone number, include that as well.
4. Provide the enrollee’s Plan ID number. This number is essential for identifying the specific plan associated with the enrollee.
5. If the request is being submitted by someone other than the enrollee, complete the sections for the requestor’s information, including their name, relationship to the enrollee, and contact details.
6. If applicable, attach documentation showing the authority of the requestor to represent the enrollee. This may include a completed Authorization of Representation Form CMS-1696 or a similar document.
7. Indicate if you are requesting an expedited decision by checking the appropriate box. If additional support from a doctor is available, attach it to this request.
8. Explain the reasons for the appeal in the provided section. If necessary, attach additional pages or information to support your case, such as statements from your doctor or medical records.
9. Sign the form. This can be done by the enrollee, their doctor, or the authorized representative.
10. Date the form before submission. Review all entered information for accuracy.
11. Finally, save any changes made to the form. You can download, print, or share the form as necessary for submission.

Complete your appeal request online today to ensure your voice is heard.