Get Florida Blue Appeals Fax Number

BlueMedicare HMO/PPO/RPPO Member Grievance and Appeal Form Mail to Florida Blue/Florida Blue HMO PO Box 41609 Jacksonville FL 32203-1609 Attn Medicare Advantage Member Grievances Appeals Fax 305-437-7490 Please read and sign the statement below. You may mail or fax it to the address/fax number provided above. I hereby request a review of the Grievance or Appeal described below and understand that the receipt of this Grievance and Appeal Form by Florida Blue constitutes a request for review by the Local Office. BlueMedicare HMO/PPO/RPPO Member Grievance and Appeal Form Mail to Florida Blue/Florida Blue HMO PO Box 41609 Jacksonville FL 32203-1609 Attn Medicare Advantage Member Grievances Appeals Fax 305-437-7490 Please read and sign the statement below. You may mail or fax it to the address/fax number provided above. I hereby request a review of the Grievance or Appeal described below and understand that the receipt of this Grievance and Appeal Form by Florida Blue constitutes a request for review by the Local Office. I understand that in order for Florida Blue to review my Grievance or Appeal Florida Blue may need medical or other records for information relevant to my Grievance or Appeal* Accordingly I authorize those persons or entities that have any medical or other records or knowledge of me to release such information to Florida Blue in order for Florida Blue to complete its review of my Grievance or Appeal* Date Individual s Signature PLEASE PRINT CLEARLY AND COMPLETE ALL OF THE INFORMATION REQUESTED BELOW Individual Name ID Card Number Address City Zip County Day Phone Employer if applicable Date of Service if applicable Condition/Diagnosis if applicable Please describe the nature of your Grievance or Appeal and any facts you feel should be considered in the review of your Grievance or Appeal Use additional sheets if necessary Florida Blue is a Medicare Advantage Organization with a Medicare contract. If the problem involves unpaid bills please attach a copy of the bill s or a completed claim form* If you have any questions please contact our Member Services number at 1-800-926-6565 for information* TTY users should call 1-800-955-8771. Our Member Services Department is open from 8 00 a*m* 9 00 p*m* ET seven days a week all year long. We have free language interpreter services available for nonEnglish speakers. A Member Services Representative will be happy to assist you. You may mail or fax it to the address/fax number provided above. I hereby request a review of the Grievance or Appeal described below and understand that the receipt of this Grievance and Appeal Form by Florida Blue constitutes a request for review by the Local Office. I understand that in order for Florida Blue to review my Grievance or Appeal Florida Blue may need medical or other records for information relevant to my Grievance or Appeal* Accordingly I authorize those persons or entities that have any medical or other records or knowledge of me to release such information to Florida Blue in order for Florida Blue to complete its review of my Grievance or Appeal* Date Individual s Signature PLEASE PRINT CLEARLY AND COMPLETE ALL OF THE INFORMATION REQUESTED BELOW Individual Name ID Card Number Address City Zip County Day Phone Employer if applicable Date of Service if applicable Condition/Diagnosis if applicable Please describe the nature of your Grievance or Appeal and any facts you feel should be considered in the review of your Grievance or Appeal Use additional sheets if necessary Florida Blue is a Medicare Advantage Organization with a Medicare contract.