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OFFICE OF THE SECRETARY OF STATEARCHIVES DIVISIONDENNIS RICHARDSONMARY BETH HERKERTSECRETARY OF STATEDIRECTORLESLIE CUMMINGS800 SUMMER STREET DEPUTY SECRETARY OF STATESIDE, OR 97310 5033730701PERMANENT

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How to fill out fidelis reconsideration form 2022

01

To fill out the Fidelis reconsideration form 2022, follow these steps:

02

Obtain the Fidelis reconsideration form for the year 2022.

03

Read the instructions provided on the form carefully to understand the requirements.

04

Fill in your personal information such as name, address, and contact details.

05

Provide details about your current Fidelis health plan, including the plan name and membership number.

06

Clearly state the reason for your request for reconsideration. Include any supporting documentation if necessary.

07

Sign and date the form.

08

Make copies of the filled-out form and all supporting documents for your records.

09

Submit the completed form and supporting documents to the designated Fidelis representative or office.

10

Follow up on your request if needed, by contacting the Fidelis customer service or using the provided contact information on the form.

11

Note: It is advisable to keep a copy of the submitted form and any related correspondence for future reference.

Who needs fidelis reconsideration form 2022?

01

Anyone who wishes to request a reconsideration of their Fidelis health plan for the year 2022 may need the Fidelis reconsideration form. This form is required for individuals who believe there has been an error or misunderstanding in the determination of coverage, claims, benefits, or any other aspect of their Fidelis health plan. It is designed to give individuals the opportunity to present their case and provide relevant information to support their request. Whether you are a Fidelis member, an authorized representative, or a healthcare provider acting on behalf of a patient, you may need to use the Fidelis reconsideration form 2022.

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What is fidelis reconsideration form?

The Fidelis reconsideration form is a document used to request a review of a decision made by Fidelis Care.

Who is required to file fidelis reconsideration form?

Any individual or entity that disagrees with a decision made by Fidelis Care may be required to file a reconsideration form.

How to fill out fidelis reconsideration form?

To fill out the Fidelis reconsideration form, you must provide your personal information, details of the decision being challenged, and any supporting documentation.

What is the purpose of fidelis reconsideration form?

The purpose of the Fidelis reconsideration form is to give individuals a chance to request a review of a decision made by Fidelis Care.

What information must be reported on fidelis reconsideration form?

The Fidelis reconsideration form typically requires information such as your name, contact information, member ID, and details of the decision being challenged.

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