Medicare Plan (Ma, Mapd And Part D) Appeals & Grievances Form Page 2
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5Medicare Plan Appeals & Grievances form 2 of 5
Are you completing this form for the member? If yes, give your name, address and phone number:
First name
Last Name
Phone number
–
–
Address
City
State
ZIP code
What is your relationship to the member?
Spouse or partner
Relative
Attorney
Estate representative
Other _______________
Please include a copy of the paperwork showing you have the legal right to act for the member.
Examples: Power of Attorney and Appointment of Representative (AOR) form. You can find the
AOR form here:
CMS012207.html
Information about your plan
Plan name
Member ID number
Group number
Information about your issue
Date of service
Claim number
Provider
Location
Prescription drug name
Please tell us what happened. (Examples: you asked the plan to pay for medical care or a prescription
drug and we denied it.) You may attach extra pages if you need more space. Be sure to include them
when you send this form.
IR_170327_114708
MRAMR2810AG
SPRJ35121
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Parent category: Medical