Fill in once, keep it accessible — your critical insurance details, provider contacts, and escalation paths in one place for when you need them fast.
Worksheet · Print FriendlyEmergency ReferenceFree - No Email Required
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Photograph both sides of your insurance card and save it to a secure location on your phone. In an emergency you may not have the physical card.
Provider Contacts
Provider / Specialist
Specialty
Phone
Fax
Portal / Notes
Primary Care Physician
Specialist
Specialist
Preferred Hospital / Facility
Current Medications — Critical Reference
Medication
Dose
Frequency
Condition Treated
Prescribing Provider
Escalation Paths — Know These Before You Need Them
Prior Authorization — Denied or Urgent
Insurer Auth Phone
Auth Reference Number
Appeal Deadline
Claim Dispute or Billing Issue
Member Services Phone
Always request a case number when disputing a claim by phone.
State Department of Insurance
State
DOI Website / Phone
Complaint Filing URL
Federal Escalation (ERISA / Self-Insured Plans)
DOL EBSA
Website
dol.gov/agencies/ebsa
Phone
1-866-444-3272
Quick Reference — Who to Call and When
Situation
First Call
If Unresolved
Prior auth denied — first time
Provider's office authorization team
Member Services; request appeal process
Urgent prior auth needed
Provider's office — ask for expedited submission
Member Services — request expedited review
Appeal denied
Member Services — request external review info
State DOI or DOL EBSA (self-insured)
Unexpected bill — high amount
Hospital or provider billing department
Member Services — confirm coverage applied correctly
Medication not at pharmacy
Pharmacy — confirm PA on file
Provider's office — confirm PA status
Plan not responding
Member Services — document call date and rep name
State DOI complaint
Medicare concern
1-800-MEDICARE (1-800-633-4227)
CMS or your State Health Insurance Assistance Program (SHIP)
Notes — Active Issues and Dates
Issue
Date Started
Last Action Taken
Next Step / Deadline
Print this sheet, fill it in completely, and store it somewhere accessible — in a medical binder, your phone's notes app, or with someone who acts as your healthcare advocate. Update it any time your plan, providers, or medications change.
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