Medicare appeal form

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. Name of person filing this appeal (if different from member, you must also submit an Appointment of Representative form if you have not - fill it out here)

First name
Middle initial
Last name
Relationship to member

Certification

12. E-signature *This question is required.

Next, review your form before you submit it. Reminder that if someone other than yourself is submitting the appeal, an AOR form is required.

Medicare appeal form - OLD

Online Medicare appeal request

Tell us why we should reconsider our decision

Other information

Certification