Sample Health Insurance Claim Appeal Form

Part 1: The Basic Tools, Chapter 3: Developing a Systematic Approach to Dealing with Health Insurance Page 16

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Table 10 - Sample Claim Appeal Form

Claim Appeal

• Identification #
•  
• Name of Policyholder
•  
• Name of Patient
•  
• Address
•  
• City
•  
• State/ZIP
•  
• Telephone
•  
• Provider
•  
• Date of Service
•  
• Please Note
•  
• Documentation Attached
•  

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