PROVIDER INFORMATION

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PROVIDER INFORMATION - Description


PROVIDER NAME GROUP NPI ADDRESS PHONE Description of action to appeal MEMBER INFORMATION AND CONSENT I agree to allow the provider listed above to file an appeal on my behalf with Maryland Phy Download

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1 PROVIDER INFORMATION PROVIDER NAME: __
PROVIDER INFORMATION PROVIDER NAME: _________________________________________________________________________________ GROUP: ______________________________________________________ NPI ______________________________ ADDRESS ______________________________________________________________ PHONE ___________________ Description of action to appeal: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ MEMBER INFORMATION AND CONSENT I agree to allow the provider listed above to file an appeal on my behalf with Maryland Physicians Care. This will be an appeal of the action taken by Maryland Physicians Care that is described above. I have read this consent form or have had it read to me and it has been explained to my satisfaction. I understand this information on the consent form and give my consent to this provider to file an appeal for me. MEMBER NAME (print) ____________________________________________________________________________ DATE OF BIRTH ___________________________ MEMBER ID# ___________________________________________ ADDRESS________________________________________________________________________________________ CONSENT FROM A DESIGNATED REPRESENTATIVE OR OFFICE STAFF WITNESSES The member listed above is unable to sign this consent form because of the reason(s) listed below. ________________________________________________________________________________________________________________________________________________________________________________________________ I am authorized to consent on behalf of the member and I hereby give my consent:

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