Virginia Medicaid/famis Appeal Request Form printable pdf download

VIRGINIA MEDICAID/FAMIS APPEAL REQUEST FORM

(For Client Appeals Only)

Last Name of Medicaid/FAMIS Applicant/Recipient:

First Name:

Middle Initial:

Suffix: (e.g., Sr., Jr., II, III)

Zip Code – 9-Digit

Mailing Address (Street or Post Office Box)

City

State

Date of Birth:

Gender:

Medicaid/FAMIS Case #:

Health Care #:

(

) Male (

) Female

Social Security #:

Primary Telephone #: (area code and number)

Email Address:

___ ___ ___ - ___ ___ - ___ ___ ___ ___

_____________________________________________

__________________________________________________

Alternate Telephone #: (area code and number)

Fax #: (area code and number)

PLEASE SEND A COPY OF THE DENIAL/TERMINATION NOTICE

REGARDING THE DECISION YOU ARE APPEALING.

I am appealing the decision of (agency name) ________________________________________________________

The date on the letter or date I was told about the Medicaid/FAMIS decision is:___________________________

The name of the person who wrote to me or spoke to me about the decision I am appealing is:

Name: _______________________________ Title: _____________________Telephone Number: _________________

The agency (check the appropriate space):

( ) Denied my application or terminated my coverage for ( ) Medicaid or ( ) FAMIS.

( ) Refused to take my application for ( ) Medicaid or ( ) FAMIS.

( ) Failed to determine my eligibility within the time limit for ( ) Medicaid ( ) FAMIS

( ) Declared me not disabled.

( ) Requested repayment of benefits paid for medical services previously received.

( ) Denied or terminated waiver services. Name the waiver: _______________________ Service ___________________

( ) Denied medical services or authorization for medical services. Name of service: _____________________________

( ) Transferred or discharged me from a nursing facility. Name of facility: ___________________________________

( ) Took other action that which affected my receipt of Medicaid, FAMIS or medical services.

Are you a community spouse appealing the income or resource determination for your spouse? ___Yes ___No

. _________________________________________

Write a brief statement about why you are requesting an appeal

______________________________________________________________________________________________

Preferred spoken language: ________________________*Preferred written language: ________________________

DO YOU NEED AN INTERPRETER? ( ) YES ( ) NO

**IMPORTANT NOTIFICATION**

The Department of Medical Assistance Services may recover expenses paid on behalf of clients when Medicaid or FAMIS coverage is

continued during the appeal process and the hearing officer upholds the agency’s action. Expenditures made for medical

services (including MCO capitation fees) from the original effective date of the proposed closure or reduction through the actual

date of closure or reduction will be subject to recovery.

*DO YOU WISH TO RECEIVE CONTINUED COVERAGE DURING THE APPEAL PROCESS IF YOU QUALIFY? __YES __ NO

This section must be completed only if the client will be represented by another individual during the appeal process.

Representative’s Name:

________________________________

_______________________

Firm or Organization:

_____________________________________________________________________________________

Address:

__________________________________

Area Code and Telephone number:

Signature of Client: __________________________________

Date: __________________________

This form must be signed by the adult client, spouse, or parent (if the client is a minor child). If a representative who is not an attorney signs this

form, the adult client must provide a signed statement or form authorizing that individual to act on his/her behalf during the appeal.

See other side for additional instructions.

July 2015

Virginia Medicaid/famis Appeal Request Form

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