Member Appeal Form – PayerFusion

Step 1 of 2

Please provide the following information for the primary Insured/Member.
(This information may be found on the front of your ID card.)

Today’s Date

Member’s ID Number

Plan Type

Medical

Dental

Member’s Group Number (Optional)

Member’s First Name

Member’s Last Name

Date

Member’s E-mail Address

Please provide the following information for the person you are submitting the request for.

First Name

Last Name

Birthdate (mm/dd/yyyy)

Relationship to person requesting the appeal

Self

Spouse

Child

Other

Note: If your selection is spouse, child (18 years of age or older) or other, please complete and include the Authorized Representative Form with your request.

Please advise if the appeal is related to:

Pre-Service

Post Service