Denial of Health Benefits Questionnaire

Thank you for filling out this questionnaire. In order to determine if we can be of service to you, it will be useful for you to answer a few specific questions. At the end of the questionnaire, hit the SUBMIT button.

If you prefer you may fill the form, print it and fax to us at (206) 374-7377
Or, you may print the form, scan it, and email it to:
Most find filling it out and hitting the SUBMIT button to be easiest.

Click here for the printable version.

What health insurance benefits are being denied:

The reason the health insurer gave for denying the benefits:

Health care provider providing services the insurer is not paying:

The value of the benefits that have been denied:

Have you appealed the denial?
If yes, date of appeal:       
Appeal granted?
         If not, date appeal was denied:       


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