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This version of the form is not currently in use and is provided for reference only. Download this version of
Form FIS2369
for the current year.
Form FIS2369 Surprise Medical Billing Request for Review of Calculation of Charges - Michigan
What Is Form FIS2369?
This is a legal form that was released by the Michigan Department of Insurance and Financial Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is the purpose of Form FIS2369?
A: Form FIS2369 is used to request a review of the calculation of charges for surprise medical billing in Michigan.
Q: Who can use Form FIS2369?
A: Any individual who has received a surprise medical bill in Michigan can use Form FIS2369.
Q: What is surprise medical billing?
A: Surprise medical billing is when a patient receives an unexpected bill for medical services that they thought were covered by their insurance.
Q: What information is required on Form FIS2369?
A: Form FIS2369 requires information such as the patient's name, insurance information, details of the medical service, and the reason for the dispute.
Q: What happens after submitting Form FIS2369?
A: After submitting Form FIS2369, the insurance company will review the calculation of charges and make a determination. You will be notified of the outcome.
Q: Can I appeal the decision made after submitting Form FIS2369?
A: Yes, if you disagree with the decision made after submitting Form FIS2369, you have the right to appeal the decision.
Q: Is there a deadline for submitting Form FIS2369?
A: Yes, Form FIS2369 must be submitted within 1 year of receiving the surprise medical bill.
Form Details:
- Released on May 1, 2021;
- The latest edition provided by the Michigan Department of Insurance and Financial Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form FIS2369 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.
Download Form FIS2369 Surprise Medical Billing Request for Review of Calculation of Charges - Michigan
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