Member Appeal Form


Member Information


Last Name:
First Name:
Middle Name:

Address:
Telephone:

City:
State:
Zip Code:

Member ID:
Date of Birth:
Sex:




Doctor's Name:

Appeal Information


1. What do you want to appeal? (List item / service / med that is denied / deferred / modified)

2. When was this denied? (List date denied. This can be the date on your NOA letter)

3. Why is this being appealed? (List why this is medically necessary for you)

4. Please list any records you are sending in with this form: (Such as: a copy of your doctor's notes or an x-ray)

5. Have you tried any other things (Meds / Treatments)?



If you selected Yes, please explain:

6. Will you require language assistance?



If you selected Yes, what language do you speak?

Your Rights


  • Health Plan of San Joaquin will send me an appeal resolution within 30 days of getting this appeal.
  • My cooperation is voluntary.
  • I have the right to disenrollment.
  • I have the right to contact the Department of Managed Health Care.
  • I have the right to a State Fair Hearing (Medi-Cal members only).

I understand my rights as listed above.

Signature (type your name):
Date:

I allow Health Plan of San Joaquin to get medical records, claims records, and other records. These records will be used for my appeal.

Signature (type your name):
Date:

Assistance


Did someone help you complete this form?



If you selected Yes, please complete the fields below, and complete the Authorization for the Use and Disclosure of Health Information Form.

Name:
Relationship:

Address:
Telephone:

Signature (type your assistor's name):
Date: