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Complaint or appeal form

I want to report a complaint or appeal

1. Complaint or appeal details
 

Please provide details of the complaint or appeal in the fields below. All fields marked with an asterisk (*) are required. 

 

*Check the one that applies
Date of incident or notice of denial received
Full details of your complaint or appeal


2. Member information

 

Please provide the following information. All fields marked with an asterisk (*) are required.

Example: 12345
Example: 1234567890
*Are you filing this complaint or appeal on behalf of someone else?

 

Important note:

fast decision

 

If you or your provider believes that waiting 30 days for a standard decision could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your provider indicates that waiting 30 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your provider’s support for an expedited appeal, we will decide if your case requires a fast decision.

Today's date

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