Fillable Virginia Medicaid/famis Appeal Request Form printable pdf download

VIRGINIA MEDICAID/FAMIS APPEAL REQUEST FORM

(For Recipient Appeals Only)

First Name of Medicaid/SLH/FAMIS Applicant/Recipient:

Middle Name:

Last Name

Street or Post Office Box:

City and State:

Zip Code – 9-Digit:

Contact Telephone #:

Medicaid/SLH/FAMIS Case #:

Social Security #:

Other Telephone #:

PLEASE SEND A COPY OF THE DENIAL LETTER OR NOTICE REGARDING THE ACTION YOU ARE APPEALING

( ) I am appealing the action of (agency name) ________________________________________________________

( ) I am a community spouse appealing the income/resource maintenance standard.

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

The person who spoke with or wrote to me telling me about the action that I am appealing is:

Name: _______________________________ Title: _____________________Telephone Number: _________________

The agency (check the appropriate space):

( ) Placed/continued me in the Client Medical Management Program ___________________________________

( ) Denied me medical services or authorization for medical services ____________________________________

( ) Delayed my receipt of covered medical services. Name of service: ___________________________________

( ) Declared me not disabled by: (please check one) Medicaid Disability Unit ( ) Social Security ( )

( ) Changed, denied or proposed a change to my nursing home level of care

( ) Took other action which affected my receipt of Medicaid or medical services

( ) Failed to determine my eligibility within the time limit for: (please check one) ( ) Medicaid ( ) SLH ( ) FAMIS

( ) Declared me ineligible or canceled my eligibility for

Signature of Appellant:

Date: __________________________

This form must be signed by the client. If this form is being signed by anyone other than the Medicaid, SLH, or

FAMIS client, please complete the next section and see the back of this form.

To be completed only if the client wishes to appoint someone to represent them during the appeals process

Name:

___________________________________________________________

Address: ___________________________________________________________

Area Code and Telephone number: _____________________________________

**IMPORTANT NOTICE**

The Department of Medical Assistance Services shall recover expenses paid on behalf of clients when Medicaid

coverage is continued during the appeal process and the Hearing Officer upholds the agency’s proposed action.

Expenditures made for medical services from the original effective date of the proposed closure or reduction through

the actual date of closure or reduction will be subject to recovery.

I am requesting a hearing because:

See other side for instructions.

DMAS-200 07/11

Virginia Medicaid/famis Appeal Request Form