[Insurers may insert an address block directing
insureds to submit this form to a specific address.]


HEALTH CARE APPEAL REQUEST FORM

You may use this form to tell your insurer you want to appeal a denial decision.
Insured Member’s Name ____________________ Member ID # _____________________
Name of representative pursuing appeal, if different from above_______________________
Mailing Address __________________________ Phone # _________________________
City __________________ State __________ Zip Code _________________
Type of Denial: Denied Claim Denied Service Not Yet Received
Name of Insurer that denied the claim/service: ____________________________________
If you are appealing your insurer’s decision to deny a service you have not yet received, will a 30
to 60 day delay in receiving the service likely cause a significant negative change in your health?
If your answer is “Yes,” you may be entitled to an expedited appeal. Your treating provider must
sign and send a certification and documentation supporting the need for an expedited appeal.
What decision are you appealing? _____________________________________________
_________________________________________________________________________
_________________________________________________________________________
(Explain what you want your insurer to authorize or pay for.)
Explain why you believe the claim or service should be covered:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Attach additional sheets of paper, if needed.)
If you have questions about the appeals process or need help to prepare your
appeal, you may call the Department of Insurance Consumer Assistance number
(602) 364-2499 or 1-(800) 325-2548, or [name of insurer] at
_____________________.
Make sure to attach everything that shows why you believe your insurer should cover your
claim or authorize a service, including: Medical records Supporting documentation
(letter from your doctor, brochures, notes, receipts, etc.) **Also attach the certification from your
treating provider if you are seeking expedited review.
_____________________________________________ ______________________
Signature of insured or authorized representative Date

602-932-8113.