Designation Of Representative As Authorized Representative For The Disputed Claims Process Form printable pdf download

Designation Of Representative As Authorized Representative For The Disputed Claims Process Form

FEDERAL EMPLOYEE PROGRAM

DESIGNATION OF REPRESENTATIVE AS AUTHORIZED REPRESENTATIVE

FOR THE DISPUTED CLAIMS PROCESS

Name of the Blue Cross and Blue Shield Service Benefit Plan member:

______________________________________________________________________________

Name of person granting authorization and relationship to Service Benefit Plan member (if other

than the member) (e.g., parent, personal representative):

________________________________________________________________________

I designate the following representative_______________________________________ (insert

name of doctor, hospital division, laboratory, health plan or other entity) as my authorized

representative to appeal the claims decision listed below:

This authorization is for the sole purpose of allowing me, as the member, or my named personal

representative to dispute the items noted below, and expires upon completion of the disputed

claims process:

Pre-Service Reference #____________________________________________________

Claim #_________________________________________________________________

Refund Request Document #________________________________________________

Other________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________

Designation Of Representative As Authorized Representative For The Disputed Claims Process Form