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**
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Name of the individual wishing to appeal a claim for private plan benefits
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**
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--
(xxx-xx-xxxx)
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(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address of the individual
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**
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Contact number of the individual
(333)333-3333
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**
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Name of Employer
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**
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(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address of the employer
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**
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Name of the Insurance Carrier
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**
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(MM/DD/YYYY)
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(MM/DD/YYYY)
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-
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**
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(MM/DD/YYYY)
Date the determination was made
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**
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