Mail to:
Florida Blue HMO
Attn: HMO Appeals
P.O. Box 41609
Jacksonville, FL 32203-1609
HMO Health Plan Grievance and Appeal Form for use with myBlue, BlueCare and SimplyBlue plans
I understand that in order for Florida Blue HMO to review my appeal, they may need medical or other records
or information relevant to my appeal. Accordingly, I authorize persons or entities that have any medical or
other records or knowledge of me or my dependents to release such information to Florida Blue HMO in
order for them to complete the review of my appeal. These persons or entities may include any:
1. Licensed physician
2.
Medical practitioner
3.
Hospital
4.
Clinic or other medical or medically-related provider
5. Insurer
6.
Employer
7.
Other organization,institution orperson
I specifically authorize the release of the following records or information if pertinent to my appeal: Any and
all medical records and information about, associated with or with reference to:
1. A positive test result for HIV infection
2.
ARC
3. AIDS
4.
Alcohol or drugdependency
5.
Mentalandnervousdisorders
For help, please call the customer service number on back of your member ID card.
Date: Individual’s Signature:
PLEASE PRINT CLEARLY AND COMPLETE ALL OF THE INFORMATION REQUESTED BELOW
Patient’s Last Name: Patient's First Name:
Date of Birth:
Member/Contract Number
(letters and numbers):
Street Address: State and Zip Code:
Phone Number:
Employer (if applicable):
Group/Plan Number on ID Card:
Claim Number (If available):
Date of Service Being Appealed (Use additional sheets, if necessary):
Condition/Diagnosis (Use additional sheets, if necessary):
Please describe the nature of your grievance and any facts you feel should be considered in the review of your
grievance. Use additional sheet(s) if necessary. If the problem involves unpaid bills, please attach a copy of the
bill(s) or a completed claim form.
Note: Correspondence will be sent directly to the benefit address we have on file for the member referenced in the appeal.
16297 0517R
HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. These companies are Independent Licensees of the
Blue Cross and Blue Shield Association. Florida Blue HMO does not discriminate on the basis of race, color, national origin, disability, age,
sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-352-2583 (TTY: 1-877-955-8773)
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-352-2583 (TTY: 1-800-955-8770)
