Appeal Claim Form Voluntary Hospitals House Staff Benefits Plan

Appeal Claim Form

Voluntary Hospitals House Staff Benefits Plan
What Should I Have Prior to Submitting?
• CIR Member ID #
• Member ID # (starts at 900) located on your Davis Vision Card
• A copy of ALL receipts as ONE document if possible
Don’t have your Member ID #? Please contact the Benefits Office at (212) 356-8180.
MEMBER INFORMATION
Member Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hospital
Member ID
Claim Number
CONTACT INFORMATION
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Format: (000) 000-0000.
CLAIM INFORMATION
Please name the type of claim the appeal is for:
Please write below, the reason the claim was denied and why you are requesting an appeal:
WHAT HAPPENS AFTER YOU SUBMIT YOUR APPEAL FORM?
1. You'll receive a confirmation email in receipt of your appeal request.
2. We'll review your appeal, including all documentation you have provided and may contact you to request additional information, clarification and to discuss your appeal.
3. You will be notified in writing of the decision of the Board of Trustees or from the Fund within 60 days of the date your request for review was received, unless there are special circumstances, in which case you will be notified of the decision within 120 days.
4. You can contact the Fund Office by phone at (212) 356-8180, Monday through Friday, 9:00am - 5:00pm EST.
Attach scanned documents below.

Cancelof
By submitting this form, I certify all the information I have provided is accurate and complete. I understand that failure to provide complete and accurate information may result in the delay or denial of my appeal.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Should be Empty:

Appeal Claim Form

MEMBER INFORMATION

CONTACT INFORMATION

CLAIM INFORMATION

WHAT HAPPENS AFTER YOU SUBMIT YOUR APPEAL FORM?