consent form

Grievances, Appeal, and/or External Review Consent for Medication I, ____________________________________, give consent...

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Grievances, Appeal, and/or External Review Consent for Medication

I, ____________________________________, give consent to Joyce Patient Name

Tan, a Patient Advocate from Premier Pharmacy Services and my Representative, to submit grievances, appeals, and/or external reviews for _______________________________________________________ List name of drugs

to my pharmacy benefit provider and/or insurance plan on my behalf. I am also giving Joyce Tan consent to call and check on the status of my grievance, appeal, and/or external review.

_______________________________________________________ Patient Signature

_______________________________ Date