Health Insurance Appeals Intake – Health Insurance Appeals

Name

First

Last

Phone

State of Residence

What type of health insurance do you have (private employer, government plan, marketplace, Medicare, Medicaid)?

Insurance of (please

Insurance company or claims administrator

Summarize Your Situation (please do not include medical records or your Social Security number)

Please briefly describe what happened, including what treatment or service was denied, when the denial occurred, and why you believe it should be covered. You can also include details concerning any appeal deadlines, letters you’ve received, or anything else you think is important.

Urgency

Urgent / facing deadline
Not urgent, but want to pursue appeal
Not sure

Consent and Acknowledgment — Please read and check each box below to acknowledge and consent to the following:

I understand that submitting this form does not create an attorney-client relationship with The Hufford Law Firm PLLC or any affiliated law students or other individuals working with the firm to assist in this project.
I consent to the information I provide being reviewed by The Hufford Law Firm PLLC, by law students working under the supervision of the firm as part of a pro bono assistance program, or by other attorneys or employees of nonprofit organizations working with the firm to assist in this project.
I consent to being contacted for more information in response to this form either by email or by phone.
I understand that submitting this form does not guarantee that The Hufford Law Firm PLLC will take on my case or file an appeal on my behalf.
I understand that I am responsible for taking any necessary steps to protect my rights, including meeting all applicable deadlines, and that The Hufford Law Firm PLLC and anyone working with the firm to assist in this project does not bear any legal responsibility for ensuring that you comply with your the legal requirements relating to your appeal.
I have read and agree to the Privacy & Disclaimer Notice, and I understand how my information will be used.