Appeal Number:

External Appeal Form (Health Benefits Plan Members Bill of Rights Law) I, , hereby request that the Director, Department of Health perform an external review of the final decision rendered by  , under the Health Benefits Plan Members Bill of Rights.

1.	Description of External Review Requested (Check one of the following): A.  Medical Necessity (Urgent or Emergency Care) B.  Medical Necessity (Concurrent or Prospective Appeal) C.  Benefit Coverage Review

2.	Patient Information
	Patient's Name:
	Age:
	Sex:	Male     Female
	Patient's Address:
	City:	State:     Zip:
	Diagnosis(es):
	Procedure(s):
	Referring Physician:
	Address:
	City:	State:     Zip:
	Telephone:
	Treating Facility:
	Address:
	City:	State:     Zip:
	Telephone Number:
	Fax Number:
3.	Health Plan Information
	Name of Health Plan:
	City:	State:     Zip:
	Telephone Number:
	Fax Number:
	Member ID Number:
	Date of Final Decision:	(Attach Copy)
	Bases for Appeal: