Form Dss-1473 - Request For State Appeal Form - North Carolina Department Of Health And Human Services
Download a blank fillable Form Dss-1473 - Request For State Appeal Form - North Carolina Department Of Health And Human Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dss-1473 - Request For State Appeal Form - North Carolina Department Of Health And Human Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2North Carolina Department of Health and Human Services
Hearings and Appeals Section
●
2418 Mail Service Center
Raleigh, North Carolina 27699-2418
●
Tel 919-855-3260
Fax 919-715-1910
REQUEST FOR STATE APPEAL
(To be completed by County DSS – Print legibly)
County: ___________________________ DSS Location: ___________________________________
(Address of county office = location of hearing)
DSS Worker Name: ________________________ DSS Supervisor Name: _______________________
Phone # ______________________ Ext._______ Phone # ________________________ Ext._______
E-mail __________________________________ E-mail ____________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Date of Appeal Request:
__________________________
Appellant: _____________________________________
SSN: ___________________________
Address: ______________________________________
Phone # ________________________
□
□
City, St. Zip____________________________________
DOB: __________________
M /
F
(Check sex)
Date of Application: ____________________________
Case # _________________________
□
□
Representative:
Yes or
No
If Yes: Name of representative: _________________________
Title:
________________________________________
(Attorney, Hospital worker, Relative, Friend, etc.)
Address: _________________________
Phone #:
_________________________
_________________________
_________________________
If you need an interpreter or any communication assistance free of charge in order to participate in the
State hearing process, please indicate to make reasonable accommodations:
□
Interpreter,
What language: _________________________________________________
□
Other accommodation, Explain: _______________________________________________
Attach a copy of the following to this Request for State Appeal:
(Check items attached.)
□
Copy of County’s notification letter to grant, deny, terminate, or modify assistance which prompted
the appeal
(i.e. DMA 5024, 5059, 5102, 5119, etc., DSS 8108, 8109, 8110, 8551, 8553, 8556, 8558, 8586, 8587,
8588, 8632, 8639, 8642, etc.).
□
Copy of local appeal hearing summary & decision, if applicable.
□
Copy of D34037 Medicaid Disability Determination Transmittal received from DDS, if appealing the
medical decision made by DDS. If Rationale Section of D34037 does not indicate an adoption, must
include copies of all medical records returned from DDS.
□
Copy of DMA-5135 and all related medical records, if applicable.
(Case involves a medical decision for
an Emergency Medical Assistance Alien appeal.)
□
Copy of relevant documents related to appeal
(application/recertification/trial budgets/MRA/5097s/5013/
etc. & citation of the specific regulations that was the basis for the County’s action)
.
DSS-1473 (Rev. 08/15) DHHS Hearings & Appeals
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dss-5272 - Facility Id Number Application Form - North Carolina Department Of Health And Human Services
Legal
Form Dma 3137 - Personal Care Services (pcs) Icd-10 Transition Form - North Carolina Department Of Health And Human Services
Legal
Form Dma 3136 - Internal Quality Improvement Program Attestation Form - North Carolina Department Of Health And Human Services
Legal
Initial Application For Assessment For A Two Component Star Rated License Form - North Carolina Department Of Health And Human Services
Legal
Child And Adult Care Food Program Form - North Carolina Department Of Health And Human Services
Legal
Child And Adult Care Food Program Nondiscrimination Policy Form - North Carolina Department Of Health And Human Services
Legal
Form Dss-1812 - General Authorization For Treatment And Medication - North Carolina Department Of Health And Human Services
Legal
Related Categories
Parent category: Legal