Individual Appeal Request form

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First Name

Last Name

Email Verification

Application ID

Date of Notice

Preferred Language

Date of Birth

Phone Number

Mailing Address

City

State

Postal Code

Preferred Contact Method

Authorized Representative

Yes

Relationship

Please specify other

Name

Address

Phone Number

Disagreement Type

Reason for Appeal

(0-1000)

The regular appeals process takes up to 90 days. You may request an expedited (faster) hearing if you have an immediate need for health services. If you request an expedited appeal, you must also include proof that the regular appeal process could jeopardize your life, health, or ability to maintain or regain maximum function. Contact Appeals at 1-855-859-2512 for more information.