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Important: This notice explains your appeal rights. Read this notice carefully. If you need help, you can call one of the numbers listed on the last page under Get help & more information. Oral interpretation is available for all languages. Access these services by calling phone number.Appeal Level: 1 [PLAN NAME/LOGO]1234APPEAL DISMISSAL NOTICE Name:Date of Notice:Enrollee Number: [Insert if available: Appeal Number:] [Insert other identifying information, as necessary (e
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