ࡱ> 02/] bjbj11 4[,\[,\ $bbb"bbbb("b0bc J c bc b$Y|bd9V c > Z: Plastic and Reconstructive Surgery Breast Reconstruction Cosmetic Surgery Robert D. Goldstein, M.D., FACS Heather A. Erhard, M.D. Diplomates American Board of Plastic Surgery American Society of Plastic Surgeons 2425 Eastchester Road 1123 Park Avenue Bronx, New York 10469 New York, New York 10128 Tel #: 718/405-7500 Tel #: 718/405-7500 Fax #: 718/405-0408 Fax #: 718/405-0408 MEMBER AUTHORIZATION FORM FOR A DESIGNATED REPRESENTATIVE TO APPEAL DETERMINATION DATE: _________________________________ Member Name: __________________________ Member ID #: ___________________________ I hereby authorize __________ M.D. to appeal ___________________determination concerning __________________________________________________________ on my behalf, as my designated representative, and, as part of the appeal, I hereby authorize____________________________________________ in its decision letter and in connection with the processing of my appeal, to communicate with my designated representative in all aspects of this appeal. I understand that these communications may contain the following: All medical and financial information contained in my insurance file, including but not limited to treatment for venereal disease ,alcoholism and drug abuse, abortion, mental disorder and HIV status relating to my examination, treatment and hospital confinement in connection with the determination, which is being appealed. I understand this information is privileged, and confidential and will only be released as specified in this authorization, or as required or permitted by law. This authorization is valid for one year period. _________________________________________________________________ Signature of member or legal representative __________________________________________________________________ Signature of witness____ Designated representative ____(check one) __________________________________________________________________ Name of witness/Designated representative (please print) __________________________________________________________________ Title (if on providers staff) or relationship member   E [ a     % & 4 H U V ` a e & ' b}uhM]hgX5h8hV5CJaJ h a5h ahV5h ah a5h ahV5>* h a5>*h ahgX5>*h ahgX5 hV5 hV5>*h_MhgX5>*h_MhgX5 hgX5>*hahgX56h(hgX56 hgX5.#9JK N  Z [  gdVgdgX$a$gdgX  LMb$%h$a$gdgX%hhgXh8hgX5h8hgX5>* hV5hVhV5hVhgX5 hgX5>* hgX5hM]hgX521h:pgX/ =!"#$% s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ gXNormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  =   8@0(  B S  ? UVWXYZ[\]^_` 55?H    %%=GMM    >*urn:schemas-microsoft-com:office:smarttags PostalCode9*urn:schemas-microsoft-com:office:smarttagsState8*urn:schemas-microsoft-com:office:smarttagsCity: *urn:schemas-microsoft-com:office:smarttagsStreet; *urn:schemas-microsoft-com:office:smarttagsaddress9*urn:schemas-microsoft-com:office:smarttagsplace =   3DHHUV`adde&'   DHHUV`adde&'   V agX  @ @UnknownG.Cx Times New Roman5Symbol3. *Cx ArialA$BCambria Math"1h3Em)@@!42QHP ?gX2!xx "Plastic and Reconstructive Surgery Lori Russo Oscar DavilaOh+'0  $0 P \ ht|$Plastic and Reconstructive Surgery Lori RussoNormalOscar Davila2Microsoft Office Word@캃@*YC@VЫ՜.+,0 hp  Dr. Goldstein@ #Plastic and Reconstructive Surgery Title  !"#$%&()*+,-.1Root Entry F:,31Tablec WordDocument4SummaryInformation(DocumentSummaryInformation8'CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q