Get the free You may use this form to tell BCBSAZ you want to appeal or grieve a decision

Appeal/Grievance Request Form You may use this form to tell BCB SAZ you want to appeal or grieve a decision. Member Name Member ID # Name of representative pursuing appeal, if different from above Phone

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6. If applicable, attach any required supporting documents to the form.
7. Review the completed form one last time for any errors or omissions.
8. Sign and date the form as instructed.
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10. Keep a copy of the filled-out form for your records.

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You may use this for various purposes such as tracking expenses, managing finances, or keeping records.

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