If you've recently been denied a claim from Parkland College, you may be feeling overwhelmed and unsure of what to do next. Fortunately, there is an option: the Parkland College Claim Appeal Form. Filing an appeal allows for your case to receive close review and careful consideration. In this blog post, we'll provide all the details on how to understand and fill out this form correctly -- so that you can get the help that you need!
| Question | Answer |
|---|---|
| Form Name | Parkland College Claim Appeal Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | parkland claims, plan provider claims appeal form, parkland community plan form, parkland health plan form |
PROVIDER CLAIMS APPEAL FORM
Complete this form and return to Parkland Community Health Plan for processing your appeal.
Provider Name: _____________________ |
Provider NPI: ____________________ |
Member Name: _____________________ |
Member ID Number: ____________________ |
Member DOB: _____________________ |
Claim Number: ____________________ |
Date of Service: _____________________ |
Amount Billed: ____________________ |
Please describe in detail, the nature of your appeal and include the date of service. Please print or write legibly. Attach additional documents if necessary.
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Attach all documentation and return to:
Parkland Community Health Plan
P.O. BOX 569150
DALLAS, TX 75356‐9150
Person Requesting Adjustment:__________________
Phone Number:__________________
Date:____________________