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  • Pa Fs 162 Form

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Ay PATIENT PAY You are responsible for $ to providers as indicated below: Name Date patient pay amount Pay to: Provider Amount SPEND DOWN: The following medical bills have been included in the deductions to determine eligibility for MA Benefits for you and your family. These unpaid bills are your responsibility and will not be paid by MA. Name of Provider Date of Service Amount IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM - - - - - - - - - - - - - -.

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SC 447-CDL 2017 SC 447-NC 2018 SC 45-A 2014 SC 45-A 2013

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If you're asking for a reconsideration, you're not appealing. It's sort of a new claim, a reopened claim, whatever you want to call it. You've got to say, “I disagree” and now there's a form that you have to use.

To appeal the ruling of a district justice, you must file an Notice of Appeal form prescribed by the Pennsylvania court administrator, along with the Notice of Judgment issued by the district justice for each person or company. The appeal must be filed within 30 days after date of judgment.

You can also write or phone your service coordinator, County Assistance Office or an enrolling agency to make an appeal request if assistance is needed. The agency will then send you the appeal request form for your signature.

You can file a petition electronically at .boardofappeals.state.pa.us. When an online appeal is submitted, the petitioner will be provided with a confirmation number that the appeal has been received. The petitioner should keep a record of that confirmation number.

Request within 90 calendar days from DOS. Note: appeals must be filed within 60 days of the notice of determination.

A petition to Commonwealth Court must be filed with the Clerk of Commonwealth Court of Pennsylvania, 601 Commonwealth Avenue, Suite 2100, P.O. Box 69185, Harrisburg, PA 17106-9185.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232