Member Information

* Last Name:
* First Name:
* Date of Birth:
* Member Number:
* Email Address:
* Phone Number:
Address:
City:
Zip Code:
Contact Name:
Relationship:
Preferred Language: English Arabic Armenian Cambodian Chinese Farsi Korean Russian Spanish Tagalog Vietnamese
Provider Name:
URL:

Appeal Information
This information becomes a part of permanent record.

* Date on Notice of Action (NOA) denial letter or Explanation of Benefit (EOB):
Date of Service, if a denied claim:
Name of Provider:
Description of the denied services, treatment or medication:

Have you appealed this decision previously?: If yes, you may file a grievance with Blue Shield of California Promise Health Plan, or request an independent Meical Review (IMR) or State Hearing.

Additional Comments: