Post Service Appeal Form PDF Details

If you’re in the military or a veteran, chances are you may have heard of the Post Service Appeal Form. This document is important for anyone in the armed forces who has been discharged under less-than-honorable circumstances because it allows them to appeal and potentially have their discharge upgraded. But understanding how this form works can be tricky – that’s why today we’ll cover everything you need to know about the Post Service Appeal Form, including what it looks like, when and how to use it, and where to get help with filing your form. Let's get started!

QuestionAnswer
Form NamePost Service Appeal Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesumr reconsideration form, umr appeal form 2021, umr post service provider request form, umr post service

Form Preview Example

UMR Post-Service Appeal Request Form

Please fill out the below information when you are requesting a review of an adverse benefit determination or claim denial by UMR.

1.

Today’s date:

6.

Plan name:

 

 

 

 

2.

Patient name:

7.

Date of service of claim:

 

 

 

 

3.

Patient date of birth:

8.

Claim control number:

 

 

 

 

4.

Member ID:

9.

Total billed amount of claim:

 

 

 

5.

Member name:

10. Provider name:

 

 

 

 

11. Name of person filling out the form:

___________________________________________

Phone number: _____________________________

12. Description of dispute:

Please fax or mail your completed form along with any supporting medical documentation to the address listed below. Please note: If no medical documentation is submitted, our review will be based on the information we currently have on file.

Fax: 877-291-3248

UMR – Claim Appeals

 

PO Box 30546

 

Salt Lake City, UT 84130 – 0546

877-805-1990 (T) 877-291-3248 (F) www.UMR.com

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Stage # 1 in filling out umr request form

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wwwUMRcom, wwwUMRcom, and wwwUMRcom of umr request form

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