Appeal Claim

If you have general questions concerning your claim or EOB, please contact Customer Service. This form should only be used for formal appeals.

Please correct the following errors:

Relations Appeal Form

* Claim Number

* Full Name of person submitting this appeal

* Provider

* Patient

* Date Of Service

* Explanation of Appeal

* What written And/Or Oral communication have you received? From whom?

* Extenuating Circumstances or Additional Information

* What is Your Expectation for Resolution?

* Your Email Address

Please attach copies of any supporting documents (referrals, claims itemized bills and letters from doctors etc.)

Add Supporting Files

Drag and Drop File Here

File size limit: 10 MB per file.

Max number of files that can be uploaded: 5

We only accept these file types: .jpg, .gif, .png, .tiff, .pdf

Terms & Conditions

I authorize EMI HEALTH to investigate my appeal. I understand that this may necessitate a review of the medical and financial records relating to my health.

I have read and agree to the terms and conditions above.

A response to the appeal may take up to 30 days