P.O. Box 30192
Salt Lake City, UT 84130-0192
Phone 844-208-9012/Fax 801-442-0762
selec th e alth .org
SHCC Appeal and Complaint Form
Member Name
Subscriber ID#
Street Address
ZIP
City
Home Ph# (
)
)
Name (person filing the appeal)
Provider
Date of Birth
State
Work/Other Ph# (
/
/
Date(s) of Service
/
/
 Ask for a quick appeal (pre-service only)  Ask to continue benefits (see below)
A. list your complaint.
B. What written and/or Verbal communication have you received? From whom?
C. List any other facts.
D. what would you like us to do?
Signature
Please attach copies of any records (such as bills or letters from doctors) and mail these to the address shown above. You may also
fax these to 801-442-0762. I GIVE SELECTHEALTH PERMISSION TO LOOK INTO MY COMPLAINT. I KNOW THAT THIS MAY CALL
FOR A REVIEW OF MY RECORDS.
Signature
Date
/
/
Name
Free interpreting services may be given upon request. Se ofrecen servicios de interpretación gratis a solicitud.
1)
While an appeal is pending, you may ask to keep your benefits if: (a) you filed the appeal timely, (b) the service was
preauthorized, and (c) the time frame covered by the auth has not ended. If the appeal is denied, you will have to pay for the cost
of the care.
2) If you choose to file a verbal appeal, you must fill out this form within five working days from the date of the verbal filing.
3) If you need help filling out this form, please call us at 844-208-9012.
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