Plastic and Reconstructive Surgery
Plastic and Reconstructive Surgery
Breast Reconstruction
Cosmetic Surgery
Robert D. Goldstein, M.D., FACS Heather A. Erhard, M.D.
Diplomates
American Board of Plastic Surgery
American Society of Plastic Surgeons
2425 Eastchester Road 1123 Park Avenue
Bronx, New York 10469 New York, New York 10128
Tel #: 718/405-7500 Tel #: 718/405-7500
Fax #: 718/405-0408 Fax #: 718/405-0408
MEMBER AUTHORIZATION FORM FOR A DESIGNATED REPRESENTATIVE TO
APPEAL DETERMINATION
DATE: _________________________________
Member Name: __________________________
Member ID #: ___________________________
I hereby authorize __________ M.D. to appeal ___________________determination concerning __________________________________________________________ on my behalf, as my designated representative, and, as part of the appeal,
I hereby authorize____________________________________________ in its decision letter and in connection with the processing of my appeal, to communicate with my designated representative in all aspects of this appeal.
I understand that these communications may contain the following:
All medical and financial information contained in my insurance file, including but not limited to treatment for venereal disease ,alcoholism and drug abuse, abortion, mental disorder and HIV status relating to my examination, treatment and hospital confinement in connection with the determination, which is being appealed.
I understand this information is privileged, and confidential and will only be released as specified in this authorization, or as required or permitted by law. This authorization is valid for one year period.
_________________________________________________________________
Signature of member or legal representative
__________________________________________________________________
Signature of witness____ Designated representative ____(check one)
__________________________________________________________________
Name of witness/Designated representative (please print)
__________________________________________________________________
Title (if on provider’s staff) or relationship member
................
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