Multi-Step Form Demo

Step 1 of 5

Find Your Vehicle

Next Step: Personal Information

* indicates a required field

Do you have your renewal notice?

YesNo

Vehicle Information

Current owner last name*

Owner last name or business trust name

Zipcode*

Does your vehicle have a license plate? *

Yes

License plate*

VIN *

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Step 2 of 5

Personal Information

Next Step: Insurance Information

* indicates a required field

Personal Details

First name*

Last name*

Driver's license number*

Home Address

Address 1*

Address 2*

City*

State*

Zipcode*

Contact Information

Primary phone number*

Secondary phone number (optional)

Email Address*

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Step 3 of 5

Insurance Information

Next Step: Payment Information

* indicates a required field

Coverage Details

Insurance Company Name *

Policy Number *

Policy Expiration Date *

Proof of Coverage

Upload Insurance Card*

All files must be uploaded in PNG, JPG, PDF formats, and must be less than 100MB in size. Files over 100MB should be split into smaller files and uploaded separately.

Browse files

Insurance-Card.png

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Step 4 of 5

Payment Information

Next Step: Member Representation

* indicates a required field

Credit Card Payment

Description of disagreement*

/500

Additional Information

If you have any other relevant files, such as medical records or scanned documents, please attach below.

Upload files

All files must be uploaded in PNG, JPG, PDF formats, and must be less than 100MB in size. Files over 100MB should be split into smaller files and uploaded separately.

Browse files

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Step 5 of 6

Member Representation

Next Step: Review & Submit

* indicates a required field

Patient Consent for External Review and Release of Medical Records

To file an external review on behalf of another individual, you must provide written authorization from that individual in order for the external review to be processed.

Is someone representing you or assisting you in filing this request? *

Yes

Authorized Representative Information

You can have a family member, friend, lawyer, or other person represent you or act on your behalf. You or your representative may ask your insurer to see any information your insurer has about the medical service(s) that is the subject of your independent external review.

First name *

Last name *

Address 1*

Address 2

City *

State *

Zipcode *

Primary phone number*

Secondary phone number

Email address

I hereby authorize this person to pursue this external review on my behalf and not (by this authorization) for any other purpose.

Document Sharing Preferences

Send to member*

Correspondence

Medical records and other documents

Send to authorized representative*

Correspondence

Medical records and other documents

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Step 6 of 6

Review & Submit

Member Information

Edit

First name

Benny

Last name

Franklin

Name of legal guardian

Bill Penn

Address 1

123 Buena Vista Drive

Address 2

Suite 456

City

Harrisburg

State

Pennsylvania

Zipcode

17101

Primary phone number

123-456-7890

Secondary phone number

Email address

bfranklin76@gmail.com

Health Plan Information

Edit

Name of insurer

Highmark Blue Shield

Health insurance plan

HM Silver Plan

Member ID number

24601

Claim Reference Number

8675309

Attachments

insurance-card.pdf

Decision Dispute

Edit

Adverse determination date

10/23/2023

What was the service denied?

CT Scan

Is this external review request for "Urgent Care" or a "Life Threatening" situation?

Yes

Attachments

physician-certification-form.pdf

Healthcare Provider Information

Provider first name

Lorem

Provider last name

Ipsum

Organization

UMPC Harrisburg

Provider type

Lorem ipsum

If other, please specify

Lorem ipsum

Address 1

Lorem ipsum

Address 2

Lorem ipsum

City

Lorem ipsum

State

Pennsylvania

Zipcode

17101

Provider phone number

123-456-7890

In Your Own Words

Edit

Description of disagreement

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Attachments

filename.pdf

Member Representation

Edit

Is someone representing you or assisting you in filing this request?

Yes

Representative first name

Benny

Representative last name

Franklin

Address 1

123 Buena Vista Drive

Address 2

Suite 456

City

Harrisburg

State

Pennsylvania

Zipcode

17101

Primary phone number

123-456-7890

Secondary phone number

Email address

bfranklin76@gmail.com

Document Sharing Preferences

Send to Member

Correspondence
Medical records and other documents

Send to Authorized Representative

Correspondence
Medical records and other documents

Member Representation

Edit

By submitting this form, you hereby request an external review of an adverse benefit determination. I authorize the Pennsylvania Insurance Department and an independent external review organization certified by the Department to obtain copies of my medical records and all other information necessary for this review. The Department, my health insurer, and my providers have my permission to release and exchange this information with the independent review organization, and with any health care provider or personal representative designated on this application form.

Full name *

Today's date*

By checking this box and providing your name and the date below, you are providing your electronic signature and affirming that all of the information you provided in this form is accurate to the best of your knowledge.

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Submit Request

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Find Your Vehicle

Do you have your renewal notice?

Vehicle Information

Personal Information

Personal Details

Home Address

Contact Information

Insurance Information

Coverage Details

Proof of Coverage

Payment Information

Credit Card Payment

Additional Information

Member Representation

Patient Consent for External Review and Release of Medical Records

Authorized Representative Information

Document Sharing Preferences

Review & Submit

Member Information

Health Plan Information

Decision Dispute

Healthcare Provider Information

In Your Own Words

Member Representation

Document Sharing Preferences

Member Representation

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