Eligibility and Reimbursement Appeal Form

Eligibility and Reimbursement Appeal Form

Use this form and either fill out the field explaining why you are requesting an appeal or upload an explanation letter. Reimbursement appeals must be accompanied by supporting documentation such as an Explanation of Benefits (EOB) or proof of payment.
Name*

First NameMiddle NameLast Name
Mailing address*

Street Address

Street Address Line 2

CityState

Zip Code
Is your home address the same as your mailing address?*

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Home address*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

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Date
Provider number
Preferred phone number*
Please enter a valid phone number.
Cell phoneLandline
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Email Address
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Please check the box that best describes the reason for your appeal, submit a letter explaining the circumstances of your appeal, and provide the documentation requested for the appeal type you have chosen. If the above items are not provided, review of your appeal may be delayed. Your appeal will be decided within 30 days of receipt of all the necessary documents.*

Eligibility determination for Dental, Vision, and Employee Assistance Program benefits. Requires documentation for hours worked during the relevant period.Reimbursement amount was paid incorrectly. Send copies of reimbursement form and documentation required from that form.Reimbursement amount was not received. Resend the reimbursement form and all required documentation.Eligibility determination for Healthcare Cost Assistance benefits. Requires documentation for hours worked during the relevant time period.Appeal to enroll in a Carewell approved plan that is not in my county.Other. Please specify in your letter the circumstances and appeal request and provide supporting documentation.
Please write the name of the plan you would like to enroll in.
Write down your reasons for requesting an appeal. Explaining the circumstances of your appeal in the box below satisfies the requirement of submitting a letter.
Upload documents here.

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Take a photo of documents.
Signature*

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Date*

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Date
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