Local Appeal Request Form
Use this form to request a Local Appeal of a decision to deny, suspend, reduce or terminate services. You can also print the form and mail it in by clicking on the following link: https://drive.google.com/open?id=0B_7XonSD1pWUS3VmWjQzTHdFb1U
Email address *
Today's Date
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What is your name? (First name, Last name) *
Your answer
I am a:
If a representative, name of person receiving services
Your answer
What is your street address?
Your answer
What is your City, State and Zipcode?
Your answer
If different, address of person receiving services
Your answer
What is your phone number?(use format xxx-xxx-xxxx)
Your answer
If different, phone number of person receiving services
Your answer
What agency is providing the services you are appealing?
What is the date on the letter telling you about this decision?
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What Action did the agency take? (found in box labeled "Action" on the Due Process letter)
What is the Effective Date of the Action (found in box labeled "Effective Date" on the Due Process letter)
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What service is being affected (found in the box labeled "Service" on the Due Process letter
Your answer
Why do you believe this decision is wrong?
Your answer
Do you want to keep the affected service in place until this appeal is complete? (Reminder - your appeal must be filed before the effective date included in the notice and the authorization for the service must not have expired)
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
Submit
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