Enrollee Information

Enrollee name

*Enrollee's First Name:

Middle Initial:

Last Name:

Enrollee's data of birth

*Date of Birth:

Month:

Day:

Year:

*Enrollee's Address:

Street 2:

* City: *State:

* Zip Code:

*Enrollee Plan ID Number:

(See your ID card)

Email Address:

* Confirm Email Address:

(mandatory if email entered)

* Enrollee Phone: Enrollee Phone Area Code - Enrollee Phone Prefix - Enrollee Phone Suffix

Yes

Complete the following Requested By section ONLY if the person making this request

is not the enrollee.

Requested By

Requester Name

*Requestor's First Name:

Last Name:

*Requestor's Address:

*City: *State:

* Zip Code:

*Requestor's Phone: Requestor Phone Area Code - Requestor Phone Prefix - Requestor Phone Suffix

Requestor's Email

Address (optional):

* Requestor's Confirmation Email:

(mandatory if email

entered)

*Requestor's Relationship to
Enrollee:

Note about Representatives: Your doctor may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Upon receipt of this online form, we will contact you if the form was submitted by anyone other than you or your doctor. Use Authorization of Representation Form CMS-1696 or equivalent to appoint a representative.

Service Request

*Provider who

Requested:

Provider's Phone: Provider Phone Area Code - Provider Phone Prefix - Provider Phone Suffix

Denied Service/Item:

Denial Letter

*Was the request denied? Yes No

Date of Denial *Month: * Day: * Year:

Call us at the number on your ID card

Expedited Decisions

If you or your doctor believes that waiting 30 calendar days for a standard decision on a medical item or service or 7 calendar days for a standard decision on a Medicare Part B prescription drug could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your doctor indicates that waiting 30 calendar days for a medical item or service or 7 calendar days for a Medicare Part B prescription drug could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your doctor's support for an expedited appeal, we will decide if your case requires a fast decision.

Check this box if you believe you need a fast decision within 72 hours.

Comments

please explain your reasons for appealing.

Signature of Requestor

* Please provide your signature by typing your name in the box:

Date

*Please check the box to verify that you are the individual completing this form.

Innovation Health Medicare is a HMO, PPO plan with a Medicare contract. Enrollment in our plans depend on contract renewal. See Evidence of Coverage for a complete description of plan benefits. Plan features and availability may vary by service area.

Please review your information carefully and make

any changes before sending.

Click the Submit button only once.

Form may require 30+ seconds to process.

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