Blue Card Appeal Request Form

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• * Required Field

  Enter Patient Information

• Patient ID Number: (include Alpha Prefix)*
• Patient Account Number: *
• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *
• Date(s) of Service: *

  +

• Group ID: *

•  

  Enter Provider Information

• Provider ID: *
• Provider Name:
• Contact First Name:
• Contact Last Name:
• Contact Email Address:
• Contact Phone Number: *
  Enter a 10 digit phone number.
• Contact Phone Ext:
• Contact Fax Number:*
  Enter a 10 digit phone number.

Date of Appeal Request:

(Please note: Appeals are for medical necessity only. All other inquiries for denials must be submitted on an inquiry form)

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif) *

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

• Checking this box will send a copy of your form to the email address provided.