Priority Health Appeal Form/FEHB

Priority Health Appeal form/FEHB
Section 1: Member information
Member name
Contract number
Address
City
Home phone/Hours available
Work phone/Hours available
Person asking for appeal
Relationship to member
State
ZIP
Name(s) of providers involved
Section 2: Appointment of representative
Part 1: To be completed by the member
I appoint the following individual, _____________________________, to act as my representative in requesting an appeal regarding the adverse
determination outlined below. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to
receive any notice in connection with my appeal, wholly in my stead. I understand that I must complete the enclosed Authorization for Release of
Personal Health Information form to allow disclosure of my personal medical and behavioral health information to my authorized representative.
x
Member signatureDate
Part 2: To be completed by the representative
I, _____________________________, hereby accept the above appointment.
x
Representative signatureDate
Representative address:
Telephone number:
Section 3: Appeal information
1. Under what section of FEHB Plan Documents do you believe this service would be covered?
2. What are the facts about this appeal?
continued >
3. What action are you asking Priority Health to take and why?
Section 4: Acknowledgement
By submitting this appeal, I understand that Priority Health will complete a thorough investigation of my appeal for review by the Appeal Committee.
I understand that this may involve contacting appropriate providers to gather relevant medical records including photos, claims information
relating to diagnosis, prognosis and treatment for physical and mental illness, mental health, substance abuse, communicable diseases, serious
communicable diseases and infections, and other conditions, ailments, sicknesses and diseases, including human immunodeficiency virus (HIV)
infections and acquired immunodeficiency syndrome (AIDS).
x
Signature (member, parent/legal guardian if member is under 18 years of age, or authorized representative)
Date
Section 5: Confidentiality
Priority Health is committed to maintaining the confidentiality of the information that you send to us. The attached form must be completed and
submitted with your appeal form if:
• You would like Priority Health to disclose any information regarding your appeal to someone other than yourself, such as your spouse, a family
member, your authorized representative, or any other third party.
• You are a parent submitting the appeal on behalf of your dependent child when the dependent child is 18 years of age or older.
• You are a parent submitting the appeal on behalf of your dependent child when the dependent child is 14 years of age or older and your appeal
involves substance abuse or behaviorial health treatment.
Return completed form to:
Priority Health
Appeal Coordinator, MS 1145
PO Box 269
Grand Rapids, MI 49501-0269
© 2015 Priority Health
priorityhealth.com
8588 01/15
Authorization for release of
personal and health information
A. Member whose information is to be released
Member name
Date of birth
/
/
Address
City
State
Contract number (on ID card)
Phone
ZIP code
I request and authorize Priority Health* to release my personal and health information. This may include claims and billing information. It may also include
medical records that Priority Health has received from medical practitioners, including records regarding general medical care, alcohol and drug abuse
treatment, psychological or psychiatric treatment, social services counseling, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome
(AIDS) or AIDS-related complex (ARC), communicable diseases or infections, venereal diseases, tuberculosis, hepatitis and demographic information.
(* “Priority Health” includes Priority Health/Priority Health Managed Benefits, Inc./Priority Health Insurance Company/Priority Health Government Programs, Inc.)
B. Type of information Priority Health may release (check ONE box)
All of my information (including personal, health, demographic, claims, billing and medical records) OR
Only my claims and billing information OR
Other, such as information regarding a specific date of service or issue (explain)
C. Who may receive your information?
Individual/entity name
Phone
Address
City
State
ZIP code
D. What is the purpose of this Authorization? (check ONE box)
At my request
Other (explain)
E. When will this Authorization expire? (check ONE box)
Note: If I fail to list an expiration date or event below, this authorization will expire one year from the date signed.
No expiration
Upon my coverage termination
On the following date
/
/
(MM/DD/YYYY)
Upon my death
Upon my written revocation
On the following event
I understand that I may refuse to sign this Authorization. I may revoke this Authorization at any time by notifying Priority Health in writing at the address
listed below. The revocation will not be effective for information that Priority Health discloses between the time that this Authorization is signed and when
the revocation is received. If Priority Health requested this Authorization, I understand that I have the right to receive a copy of this Authorization after
I sign it. I understand that Priority Health will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this Authorization.
I understand that the persons to whom information is disclosed under this Authorization may possibly redisclose the information to others without my
knowledge or consent, and therefore, the privacy of my personal and health information may no longer be protected by law.
F. Signature required
If signed by a person other than the member, please check the relationship and provide proof of authority to do so:
Parent of a minor child
Power of attorney
Legal guardian
Personal representative of deceased member
Signature
Date
/
/
Printed name
G. Finalize and send
• Form must be fully completed
• Submit form via one of the following
- Scan and email to [email protected]
- Fax to: 616.942.0616 - Mail to: Priority Health, MS 2005, 1231 East Beltline, N.E., Grand Rapids, MI, 49525-4501
This form satisfies all required elements of a valid authorization under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
© 2015 Priority Health priorityhealth.com
8588 01/15