Appeal Form "*" indicates required fields PhoneThis field is for validation purposes and should be left unchanged.Appeal to State Agency AuthorityIs this appeal about you or someone else?* Me Someone else Usually, only the person that is the subject of the appeal may start an appeal. However, you may be able to start the appeal for them if you have a legal or other relationship with the person that allows you to do so.If you have a document that shows your authority, send it to the Appeals Division as soon as possible. You can upload it here and submit it with the appeal request. The appeal may be delayed or dismissed if authority is not provided.* Drop files here or Select files Max. file size: 512 MB. What is your authority to file an appeal for this person?*Is the appeal for a person or a business?* Person Business AppellantTell us about the person the appeal is for.Name* First Middle Last If different from your legal name, what is the name you want staff to call you?CASE NUMBERPMI NUMBERDATE OF BIRTH* MM slash DD slash YYYY PREFERRED PRONOUNSSTREET ADDRESSAPARTMENT NUMBERCITYSTATEALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZIP CODEPHONE NUMBERNo phone number* No phone number EMAIL ADDRESS AgencyWhich agency took the action you are appealing? Was it a state agency, county, tribe or health plan? If you are not sure, look at who sent you the notice.*What is the date the notice was sent to you? This date is usually at the top of the notice. MM slash DD slash YYYY On what date does the notice say the action will happen? MM slash DD slash YYYY Uploading a copy of the notice with this request will help process your appeal faster. Drop files here or Select files Max. file size: 512 MB. Reason for appealWhich program or type of benefits is this appeal about?*Please explain what the agency did that you disagree with and why you are appealing. Please provide as much information as you can.*You can upload documents you would like the human services judge to see. Drop files here or Select files Max. file size: 512 MB. Continued benefitsYou may be able to keep getting your benefits at the same rate as you do now until a decision is made in the appeal. If you lose your appeal, you may have to pay back some or all of the benefits you got.* I want to keep getting benefits at the same rate as now until my appeal is decided. I want to change my benefits to whatever the notice told me until my appeal is decided. I am not getting benefits right now. The appeal is not about my level of benefits. Emergency appealDo you have an emergency and need a faster appeal? Yes No AccessIs an interpreter needed? Yes No Do you need other accommodations or special arrangements? Yes No RepresentativeIs someone representing the person in the appeal? This could be an attorney, family member, friend or other advocate Yes No Sign and submitThe reason we are asking for this information is to help the Appeals Division process your appeal. If you provide the data, it will be used by the Appeals Division to make sure the correct county or state agency is made a party to the appeal. It will also be used to determine if and when a hearing should occur or whether more information is needed before the appeal can go forward. The Appeals Division will also use the information you submit to determine if the agency took the correct action on your appeal. In addition, the agency whose action you are appealing will use the information to review what it did on your case. The agency will use it to prepare a response to your appeal or to try and resolve the matter with you. You are not legally required to provide this data and may refuse to do so. However, if you do not provide the data, it may delay the processing of your appeal and the time it takes to make a decision on it. The information you provide is private. It will not be shared with anyone who does not have a legal right to see it. For most appeals, this includes representatives from the agency whose action you are appealing, along with Appeals Division staff and other state staff who monitor and report on the program(s) under appeal. The information may also be shared upon court order or provided to the state, federal or legislative auditors. If you further appeal this decision, the information may also be shared with the district court or other entity to which you have further appealed. By signing this form, I confirm that: • I have answered all of the questions to the best of my knowledge. • I understand that I am not required to complete this form and am voluntarily completing it for the purpose of filing an appeal. • I understand how the information I give will be used and who may have access to it. • If I named a representative, that person is authorized to represent me in this appeal and to receive all information about me related to the appeal. ELECTRONIC SIGNATURE*TODAY'S DATE MM slash DD slash YYYY BusinessBUSINESS NAME*MAILING STREET ADDRESS*SUITE NUMBERCITY*STATE*ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYZIP CODEPHONE NUMBERNo phone number No phone number Contact information FIRST NAME*LAST NAME*TITLE*PHONE NUMBERNo phone number No phone number EMAIL ADDRESS* AgencyWhich agency took the action you are appealing? Was it a state agency, county, tribe or health plan? If you are not sure, look at who sent you the notice.*What is the date the notice was sent to you? This date is usually at the top of the notice. MM slash DD slash YYYY On what date does the notice say the action will happen? MM slash DD slash YYYY Uploading a copy of the notice with this request will help process your appeal faster. Drop files here or Select files Max. file size: 512 MB. Reason for appealWhich program or type of benefits is this appeal about?*Please explain what the agency did that you disagree with and why you are appealing. Please provide as much information as you can.*You can upload documents you would like the human services judge to see. Drop files here or Select files Max. file size: 512 MB. Continued benefitsYou may be able to keep getting your benefits at the same rate as you do now until a decision is made in the appeal. If you lose your appeal, you may have to pay back some or all of the benefits you got.* I want to keep getting benefits at the same rate as now until my appeal is decided. I want to change my benefits to whatever the notice told me until my appeal is decided. I am not getting benefits right now. The appeal is not about my level of benefits. Emergency appeal Do you have an emergency and need a faster appeal? Yes No Access Is an interpreter needed? Yes No Do you need other accommodations or special arrangements? Yes No Representative Is someone representing the person in the appeal? This could be an attorney, family member, friend or other advocate. Yes No Sign and submit The reason we are asking for this information is to help the Appeals Division process your appeal. If you provide the data, it will be used by the Appeals Division to make sure the correct county or state agency is made a party to the appeal. It will also be used to determine if and when a hearing should occur or whether more information is needed before the appeal can go forward. The Appeals Division will also use the information you submit to determine if the agency took the correct action on your appeal. In addition, the agency whose action you are appealing will use the information to review what it did on your case. The agency will use it to prepare a response to your appeal or to try and resolve the matter with you. You are not legally required to provide this data and may refuse to do so. However, if you do not provide the data, it may delay the processing of your appeal and the time it takes to make a decision on it. The information you provide is private. It will not be shared with anyone who does not have a legal right to see it. For most appeals, this includes representatives from the agency whose action you are appealing, along with Appeals Division staff and other state staff who monitor and report on the program(s) under appeal. The information may also be shared upon court order or provided to the state, federal or legislative auditors. If you further appeal this decision, the information may also be shared with the district court or other entity to which you have further appealed. By signing this form, I confirm that: • I have answered all of the questions to the best of my knowledge. • I understand that I am not required to complete this form and am voluntarily completing it for the purpose of filing an appeal. • I understand how the information I give will be used and who may have access to it. • If I named a representative, that person is authorized to represent me in this appeal and to receive all information about me related to the appeal.ELECTRONIC SIGNATURE*Date MM slash DD slash YYYY
