Medicare appeal form with AOR

Online Medicare appeal request

1. Priority Health contract number *This question is required.

2. First name *This question is required.

3. Middle initial

4. Last name *This question is required.

5. Address *This question is required.

Street address
Address 2
City
State
Zip

6. Email address This question requires a valid email address.

So we can send you a copy of this form once it's filled out

7. Phone number *This question is required.

Tell us why we should reconsider our decision

8. Name of the doctor or provider you went to *This question is required.

9. Date of service(s) *This question is required.

10. Details *This question is required.

Other information

11. Who is filling out this form? *This question is required.

Enter the name and relationship of the authorized representative below if it is not the member filling out this form. You and the member must also complete the Appointment of Representative section on the next page for the appeal submission to be accepted.

First name *This question is required.

Middle initial

Last name *This question is required.

Relationship to member *This question is required.

Certification

12. E-signature *This question is required.

You will review your form on the next page before you submit it. If an Authorized Representative is not submitting the form on your behalf, please disregard the Page 2 questions when reviewing your submission.

You will complete the Appointment of Representative form on the next page. Once complete, you will review your entire form before final submission.