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)? Yes No
If you selected Yes, please explain:
6. Will you require language assistance? Yes No
If you selected Yes, what language do you speak?
I understand my rights as listed above.
I allow Health Plan of San Joaquin to get medical records, claims records, and other records. These records will be used for my appeal.
Did someone help you complete this form? Yes No
If you selected Yes, please complete the fields below, and complete the Authorization for the Use and Disclosure of Health Information Form.