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3. Member’s First Name
4. Member’s Last Name
5. Member’s ID Number
6. Street Address
7. City
8. State
9. Zipcode
10. Phone Number
12. Patient’s First Name
13. Patient's Last Name
14. Date of Birth
16. Provider
17. Date of Service
18. Check Box
20. Check Box
21. What is your grievance or appeal?
22. What would you like us to do?
23. How would you like Select Health to contact you?
24. Check Box
25. File Attachment
26. Digital Signature
27. CAPTCHA
28. Check Box
29. Submit Request
30. Clear Form

Grievance & Appeals Form

Use this form for complaints about benefit coverage or denied claims.

Member Information

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Member’s First Name

Member’s Last Name

Member’s ID Number

Street Address

City

State

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Zipcode

Phone Number

Patient Information

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Patient’s First Name

Patient's Last Name

Date of Birth

Provider Information

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Provider

Date of Service

Are you requesting an expedited appeal?
By checking this box, you are requesting an expedited appeal (pre service only).

What this means... If you believe that the normal time frame to process your appeal could jeopardize your life, health, or ability to regain maximum function, you can re

Grievance & Appeal Information

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Check this box if your grievance/complaint is about the care you received
Please check this box if you were misdiagnosed, received poor care, or didn't receive the care you should have.

What is your grievance or appeal?

What would you like us to do?

How would you like Select Health to contact you?

Select an option Email Phone Mail

I give Select Health permission to look into my complaint. I know that this may require a review of my records.

File Attachment

Click to upload or drag and drop

audio/*, video/*, image/*, text/*, application/pdf Max. File Size: MB

Attach

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Digital Signature

By checking this box, I give Select Health permission to look into my complaint. I acknowledge that this may require a review of my records.

Submit Request

Clear Form