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Appeal Request Form - meritain.com

www.meritain.com

Provider Address (Where appeal/complaint resolution should be sent) Claim(s) Date of Service(s) CPT/HPCS/ Service Being disputed Explanation of your request (please use additional pages if necessary) Please return to: Meritain Health Appeals Department PO Box 41980 Plymouth MN 55441 Fax: 716-541-6374 . HE-ACTH An Aetna Company . Author:

  Aetna, Appeal, Meritain

Health Complete and send to: Meritain Health Claim Form ...

www.meritain.com

Health Claim Form Complete and send to: Meritain Health P.O. Box 853921 Richardson, TX 75085-3921 Fax: 1.763.852.5057 IMPORTANT: Please have your doctor or supplier of medical services complete the reverse of this form or attach a fully itemized bill. A diagnosis must be shown on bill. Do not submit this form if injury occurred on the job.

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Important Contact Information Introducing Meritain

www.scpmgretiree.org

Introducing Meritain Health As part of ongoing efforts to enhance the level of service provided by our vendors, Permanente Human Resources is pleased to

  Information, Important, Contact, Introducing, Meritain, Important contact information introducing meritain

REIMBURSEMENT REQUEST FORM - meritain.com

www.meritain.com

Dependent Care Reimbursement Account Expenses submitted must have been incurred for the care of a “qualifying individual” for the purpose to be gainfully employed.

  Care, Reimbursement, Request, Dependent, Request reimbursement, Dependent care reimbursement, Meritain

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