Allied

Stop-Loss Universal Appeal Notice
Self-Funded Claim Appeal Notice
Dental Universal Appeal Notice

Federal

Dental Claim Form

State

If you are interested in filing a claim appeal, use the specific forms for your state, if listed. If your state is not listed, please use the ERISA form below to file your appeal.

ERISA Form

Delaware

Delaware External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Georgia

Georgia External, Independent Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Iowa

Iowa External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Kansas

Kansas External, Independent Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Missouri

Missouri External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Nebraska

Nebraska External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

Ohio

Ohio External Claim Review Information
ERISA Form
Notice of State Claim Appeal Rights

South Carolina

South Carolina External Claim Review Information
Medical Records Release
ERISA Form
Notice of State Claim Appeal Rights

Texas

Texas External Claim Review Information
Request for a Review by an Independent Review Organization
ERISA Form
Notice of State Claim Appeal Rights

Virginia

Virginia External Review Form
ERISA Form
Notice of State Claim Appeal Rights
If you are unable to find what you're looking for, please contact Allied Client Services.