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The appeal form should not be used to submit a claim correction or as a venue for submitting medical records or EOBs.
Do you have an Authorization to Release Information (ARI) form completed for this member? *
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Legally, BCBSND cannot process this appeal without a completed Authorization to Release Information (ARI) form.
Please complete the ARI form and return to submit your provider appeal.
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Your appeal will be reviewed within 72 hours.
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