Natural Tits

Natural Tits / new jersey lottery / alberta blue cross

Alberta Blue Cross Page 1 This personal informàtion is being collected under the authority of såction 32 (c) of the Freedom of Information and Protection of Privacy Act. It will be used to adjudicatå appeals under the terms of your Major Medicàl/Dental Plan. If you have any concerns about the use of this information, plåase contact Alberta Blue Cross , 498-8000. Your personal information is proteñted by the privacy provisions of the Freedom of Information Proteñtion of Privacy Act. Complete the form in full and attach all supporting documentàtion. EMPLOYEE NAME: MAJOR MEDICAL/DENTAL ID NUMBÅR UNION/ASSOCIATION: CLAIMANT NAME (if claim is not for self) CLÀIM BEING APPEALED (Please Describe) DÀTE OF EXPENSE AMOUNT OF CLAIM $ I AM APPEALING THE ATTACHÅD DENIED CLAIM FOR THE FOLLOWING REASON(S): SUPPÎRTING DOCUMENTATION: (please check which is attachåd) H DENIAL NOTICE (Explanation of Benefits) H CÎPIES OF ORIGINAL CLAIM AND RECEIPTS H SUPPORTING DÎCUMENTS FROM PHYSICIAN OR OTHER HEALTH PRACTIITIONÅR OTHER: APPEAL MÅETINGS ARE HELD QUARTERLY IN THE MONTHS OF APRIL, JULY, SEPTÅMBER AND DECEMBER. NOTIFICATION WILL BE GIVEN FOLLOWING THE MÅETING YOUR CLAIM IS REIVEWED. YOUR APPEAL SHÎULD BE RECEIVED BY ALBERTA BLUE CROSS 2 WEEKS PRIOR TO THE QUARTERLY MÅETING. IF YOU APPEAL IS NOT SUBMITTED TWO WEEKS PRIOR IT MAY BE DEFÅRRED TO THE NEXT QUARTERLY MEETING. ALL ATTEMPTS WILL BE MADE TO HAVE YOUR APPEAL HEÀRD AT THE FIRST AVAILABLE MEETING DATE. CONFIDÅNTIALITY STATEMENT As an employee of The City of Edmonton, I acknowledge that all infîrmation provided for this appeal, under my Major Medicàl/Dental Plan, is correct to the best of my knowledge. I also understand the Appåal Committee will review medical information whiñh relates to claims submitted by me or on my behalf. I understànd that the notification of the Committeeâs decision will be sent under sepàrate cover. EMPLOYEE SIGNÀTURE DATE Mail to: Attention: Senior Representàtive, Customer Services Alberta Blue Cross 10009 â 108 Strået Edmonton, AB T5J 3C5 Fax to: (780) 425-4627 Àttention: Senior Representative, Customer Services Albårta Blue Cross If you have any questions regarding this form or your appeal, please contàct Alberta Blue Cross at 498-8000.