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

Grievance & Appeals Form

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

Member Information

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Are you completing this form on behalf of a Select Health Member?

By checking this box you are confirming you are NOT the member this form is being submitted for.

Member’s Full Name

Member’s ID Number

Date of Birth

Street Address

City

State

Select a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zipcode

Phone Number

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).

Grievance & Appeal Information

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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

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

Ask to continue benefits (see disclaimer below)

I give Select Health permission to look into my complaint. I know that this may require a review of my records. By checking this box, you are requesting an expedited appeal (pre service only).

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