1. EVERETT SCHOOL EMPLOYEE BENEFIT TRUST
    2. APPEAL FORM


     

     





    EVERETT SCHOOL EMPLOYEE BENEFIT TRUST





    APPEAL FORM

     


    DATE:              

     

    NAME:            

    ADDRESS:            

                 

     

    TO:  TRUSTEES OF EVERETT SCHOOL EMPLOYEE BENEFIT TRUST

     

    RE:  (Check One)

     

    alt

          APPEAL OF BENEFIT DENIAL BY HMA/PCN
     
    alt
    APPEAL OF ELIGIBILITY/ENROLLMENT DENIAL BY THE  EVERETT SCHOOL DISTRICT
     


    1.  Date notified of denial        .

     This date is within 180 days of the notification of the denial.

     
    2. Please attach all documentation pertaining to the benefit or enrollment/eligibility denial. The following documents are attached: (Please list)
     
                          
                          
                          
                          
                          
                          
     
    3. Please describe in your own words the reason you are appealing the benefit or enrollment/eligibility denial. You can use the space below or attach a separate document.
     
     
    4.
                       
    Name            Date
     
                  
    Signature (or signature of authorized representative)

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