Educators Mutual Insurance Association of Utah

         852 E. Arrowhead Lane

 

Murray, Utah  84107

 

801-262-7475/800-662-5851

 

 

CUSTOMER RELATIONS APPEAL  FORM

 

INSURED’S NAME:

 

SOC. SEC. NO.:

ADDRESS:

 

CITY, STATE, ZIP

 

PLAN:

EMPLOYER:

 

PHYSICIAN:

PATIENT’S NAME:

 

DATE(S) OF SERVICE:

1.  EXPLANATION OF APPEAL:

 

 

 

 

 

 

 

2.  WHAT WRITTEN AND/OR ORAL COMMUNICATION HAVE YOU RECEIVED? FROM WHOM?

 

 

 

 

 

 

3.  EXTENUATING CIRCUMSTANCES OR ADDITIONAL INFORMATION:

 

 

 

 

 

 

4.  WHAT IS YOUR EXPECTATION FOR RESOLUTION?

 

 

 

 

 

 

Please attach copies of any supporting documents (referrals, claims itemized bills, and letters from doctors, etc.) EDUCATORS MUTUAL IS AUTHORIZED TO INVESTIGATE MY APPEAL. I UNDERSTAND THAT THIS MAY NECESSITATE A REVIEW OF THE MEDICAL AND FINANCIAL RECORDS RELATING TO MY HEALTH.

 

DATE:

 

SIGNATURE: (Insured or Patient)

 

ej/hipaa/forms/customer appeal form.12-2003.doc