Insurance Authorization_release_form

Cigna Appeals Authorization SR# 1457315794 Jongsma

ID: 2b9998e447882f7a

Download

Details

Category
Vendor
Cigna Appeals
Date
Mar 10, 2023
Processed
Sep 13, 2026 1:10 AM EDT
Original File
20230310 Cigna authorization03102023.pdf

Summary

Authorization for Release of Confidential Information for Appeal Review for member Johan Jongsma (ID 10712074603, SR# 1457315794), signed 10th March 2023 by Sophia Jongsma, authorizing John Shamblin/Tanya Smith to disclose air and ground ambulance transport records from 6/28/2022 to Cigna Appeals for the claims/appeals process.

Notes

No notes yet. Click Edit to add notes.

OCR Text

Document Preview

100%
Page 1 of 1