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GRIEVANCE/APPEAL REQUEST FORM - Affinity …

GRIEVANCE/APPEAL REQUEST form *You can get an Appointment of Authorized Representative form (AOR) by using the link on our Website where you found this form . An AOR is not required for children under age 18 or for a handicapped dependent if the representative is a parent or legal guardian that is on the policy or is the appointed representative. If you are not on the policy or the appointed representative, we would need proof of legal guardianship or a signed AOR from the parent on the policy appointing you as the representative.

GRIEVANCE/APPEAL REQUEST FORM *You can get an Appointment of Authorized Representative Form (AOR) by using the link on our Website where you found this form. An AOR is not required for children under age 18 or for a handicapped dependent if the representative is a parent or legal

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Prior Auth Request Form 2013 - affinitymd.com

www.affinitymd.com

Title: Microsoft Word - Prior Auth Request Form 2013.docx Author: Glady Macalino Calalay Created Date: 20130110211302Z

  Auth

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