APPEAL NO - | Office of Health Care Ombudsman and Bill of ...
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Office of Health Care Ombudsman and Bill of Rights
APPEAL NO: __________
APPEAL FORM
I, (Member/Member Representative), hereby request
(Name of Member/Member Representative)
that the Director/Administrator of the Office of Health Care Ombudsman and Bill of Rights review the final decision rendered by __ .
(Name of Health Plan)
1. DESCRIPTION OF REVIEW REQUESTED (Check one of the following)
A. Medical Necessity (Urgent or Emergency Care)_____
B. Medical Necessity (Concurrent or Prospective Appeal)____
C. Benefit Coverage Review____
D. Other _____
2. PATIENT INFORMATION
Patient’s Name: ___________________________________________
Date of Birth: ___________________ Sex: ________
Address: ______________________ _______________ City: ___________________________ State: __________ Zip: ____________ Telephone: _______________________ FAX: ________________________
Email: _____________________________ Ward:_________
Marital Status: _______ Race: __________ Language Spoken:____________
# In Household: _________ Veteran Status ______
Employment Status ______________________ Monthly Income: ________________
Page (2)
1. MEDICAL INFORMATION
Diagnosis (es):____________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Procedure(s):_____________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________
Referring Physician:___________ ____________________________________________ Address: City, State, Zip :___________________________________________________
Telephone___________________________Fax:_________________________________
Treating Facility:__________________________________________________________
Address: City, State, Zip: __________________________________________________
Telephone: _________________________Fax:_________________________________
3. HEALTH PLAN INFORMATION
Name of Health Plan: _____________________
Address: City, State, Zip:__ _________________________________
Member Identification Number:______________________________________
Date of Final Decision: (ATTACH COPY)
Page (3)
1. BASES FOR APPEAL:
________________________________________________________________________
_______________________________________________________________________ ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____ _____________________
Signature of Member/Member Representative Date
Address: City, State, Zip: ____________________ _________________________________
Telephone: ___________________________Fax: ___________________________________
MAIL OR FAX THIS FORM WITH AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION TO:
GOVERNMENT OF THE DISTRICT OF COLUMBIA
OFFICE OF HEALTH CARE OMBUDSMAN AND BILL OF RIGHTS
ONE JUDICIARY SQUARE
441 4th Street, NW, Suite 900 South
WASHINGTON, D.C. 20001
PHONE: 1-877-685-6391
FAX: 202-442-6724
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