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maryland care appeal consent form Preview on Page 1
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The document is a consent form allowing a healthcare provider to file an appeal on behalf of a member with Maryland Physicians Care. It includes sections for provider and member information, consent for the appeal, and provisions for designated representatives or office staff to witness the consent if the member is unable to sign.
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  1. Click ‘Get Form’ to open the Provider Information form in the editor.
  2. Begin by entering the PROVIDER NAME, GROUP, and NPI in the designated fields. Ensure all information is accurate for proper processing.
  3. Fill in the ADDRESS and PHONE number of the provider. This information is crucial for communication regarding the appeal.
  4. In the section labeled 'Description of action to appeal', provide a detailed explanation of the issue being appealed. Be clear and concise.
  5. Proceed to MEMBER INFORMATION AND CONSENT. Enter your MEMBER NAME, DATE OF BIRTH, MEMBER ID#, ADDRESS, PHONE, and EMAIL in their respective fields.
  6. Sign and date the consent section to authorize your provider to file an appeal on your behalf.
  7. If applicable, complete the CONSENT FROM A DESIGNATED REPRESENTATIVE section by providing necessary details and signatures from authorized individuals.

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