Appointment of Representative Form

Blue Shield of California Appointment of Representative Form

California Grievance Form

Member Authorization Form

New Mexico Appeals and Grievance Form

With the exception of states and plans highlighted in the PDFs above, the member must file the appeal or grievance.  The member can elect to allow you to file the appeal on their behalf.  The member will need to submit a letter stating that we permission to work with the dentist on the appeal.  The address and appeals guidelines and process is available in the member's explanation of benefits (EOB).