Get Fair Hearing Request Form For Ahcccs/altcs Service Denials

Filling out the Fair Hearing Request Form is an essential step for users seeking to appeal a denial of services by AHCCCS or ALTCS. This guide provides a clear, step-by-step approach to ensure your submission is complete and accurate, ultimately supporting your rights during the appeal process.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Fair Hearing Request Form For AHCCCS/ALTCS Service Denials and open it in the editor.
2. Enter the AHCCCS/ALTCS member's information in the designated fields. Include the member's full name, address, city, state, zip code, AHCCCS ID number, date of birth, and contact phone number.
3. If the person filing the appeal is different from the member, provide their information as required, including their name, address, city, state, zip code, phone number, and their relationship to the member.
4. Fill out the section regarding the fair hearing request. Record the date you filed your appeal and the appeal number given to you. You must also note the date when your health plan denied your appeal, as you need to file this request within 30 days of that decision.
5. In the space provided, explain your reasons for requesting a fair hearing. Be thorough and clear in your explanation. If necessary, you can use the back of the form or attach additional pages.
6. Indicate whether you would like your services to continue during the appeal process by checking 'Yes' or 'No'. If you choose 'Yes', remember that the appeal must be filed within 10 days of the decision.
7. If applicable, indicate if you are requesting an expedited fair hearing by checking 'Yes' or 'No'. If you are seeking an expedited process, it is recommended that you attach supporting documentation from the member's doctor.
8. Sign the form, including the date of your signature. Ensure that the signature is from the AHCCCS/ALTCS member, their guardian, or parent. If signed by someone else, attach the necessary documentation of authority.
9. Complete the appeal filed with section, noting the health plan's name and address where the appeal is submitted. Indicate how the appeal was filed: via certified mail, fax, US mail, or hand delivery.
10. Before finalizing, make sure to keep a copy of the completed form for your records. Then, save your changes in the editor and download or print the form for submission.

Complete your Fair Hearing Request Form online today and ensure your appeal is filed correctly.