Virginia Medicaid/famis Appeal Request Form Page 2

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INSTRUCTIONS
1.
Complete this form as fully as possible or write a letter with the same information.
If you need more
space for your comments, you may include additional sheets.
2. Include names, addresses and telephone numbers.
PLEASE
PRINT.
3. The Medicaid/FAMIS applicant or recipient MUST sign the form. If the applicant or recipient
cannot sign the form, explain why you are the appropriate representative. If you hold Power
of Attorney (POA), include a copy of the POA document.
4. Mail or fax this form or letter with your notice from the agency to the address shown below.
 The appeal form or letter must be postmarked within thirty (30) days of the agency’s action.
 The appeal form or letter must be postmarked within thirty (30) days of the date you were
supposed to get a decision, but did not.
 If neither of the above addresses your situation, mail in the appeal form or letter as soon as
possible to protect your appeal rights.
SEND COMPLETED FORM OR APPEAL REQUEST LETTER TO:
Appeals Division
Virginia Dept. of Medical Assistance Services
th
600 East Broad Street, 11
Floor
Richmond Virginia 23219
Fax (804) 786-5778
IF YOU ARE NOT MAILING THE APPEAL FORM OR LETTER WITHIN 30 DAYS OF THE AGENCY’S
ACTION, PLEASE ANSWER THE QUESTIONS BELOW:
1. Did you get a denial or cancellation notice?
What was the postmark date on
the envelope?
When did you get the notice?________________________
2. If you did not get a notice, how did you learn of the denial or cancellation?
3. Have you had any problems getting mail? _________ What kind of problems?___________
___________________________________ Were problems reported to the post office?______
4. Has your address changed?______ When?___________ Did you tell the agency?________
When?______
5. Why didn’t you file an appeal within 30 days of the agency action? ____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

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