INFORMATION REQUEST FORM – APPEALS
About You
Plan ID Number:
Your Name: _______ Date of Birth: _______________________
Address:
Telephone Number:
Information Requested
Please check the plan under which you are requesting records:
___ GEHA Health Plan (FEHBP) ___CONNECTION Vision Plan ___(Other)______________________
___ Connection Dental Plus Plan ___GEHA Connection Dental Federal Plan (FEDVIP Plan)
Please provide a detailed description, including claim number(s) and/or dates of service for which you are
requesting records:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
I request a copy of records relevant to the benefit determination made by GEHA. I understand that this request for
records is not considered an appeal as described in the Disputed Claims section of my plan brochure, or other
applicable plan document.
Format: ___Paper copy
__Electronic copy
Information to be released to: __Self
__Other (Must be designated as Authorized Representative. Please fill in contact
information below. If necessary, please also include Authorized
Representative form.)
Mail to Name:
Mail to Address:
Date:
Patient or Legal Representative Signature:
Relationship to patient:
(i.e., parent, legal guardian, power of attorney, etc.)
NOTE: If the signature is not that of the patient or the parent when the child is a minor, appropriate legal documentation
is required to accept the signature.
PLEASE RETAIN A COPY FOR YOUR RECORDS AND RETURN THE ORIGINAL SIGNED FORM TO:
ATTN: Appeals
GEHA
P.O. Box 21542
Eagan, MN 55121
FAX: 816-257-3283
GE-FRM-0219-002
click to sign
signature
click to edit
![]()
