External Review Appeal to Director - Illinois Department of Insurance - insurance illinois 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Applicant' section. Enter your first name, last name, address, city, state, zip code, daytime phone number, and email. Select your relationship to the patient by checking one of the provided boxes.
3. Next, complete the 'Covered Person/Patient' section with the patient's details including their first name, last name, address, and contact information.
4. In the 'Insurance Information' section, provide details about the health carrier and subscriber. Indicate whether you have an individual plan or a group plan through an employer or sponsor.
5. Fill in the 'Health Care Provider' section with the treating provider's name and contact information.
6. Clearly state your reason for appeal in the designated area. Attach any necessary documentation such as ID cards and final denial letters.
7. Finally, sign and date the consent for external review at the bottom of the form. Ensure that all required attachments are included before submission.

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