Get Reconsideration Request Form Pdf - Delmarva - Dfmc-florida

Completing the Reconsideration Request Form is an essential step if you disagree with the findings of your review. This guide provides clear, step-by-step instructions to help you fill out the form accurately and effectively online.

Follow the steps to complete your form successfully.

1. Press the ‘Get Form’ button to access the Reconsideration Request Form Pdf - Delmarva - Dfmc-florida and open it in your editing tool.
2. Fill in the 'Provider Number' field. Ensure this is the correct number associated with your organization or agency.
3. Specify the 'APD Area' where your service is provided. This detail is crucial for proper routing of your request.
4. Complete the 'Provider/Agency Name' field with the official name of your organization.
5. Enter the 'Provider Street Address / City / State / Zip' information. Double-check for accuracy as this ensures proper communication.
6. If applicable, provide details for 'Provider Location – Site Reviewed'. This information helps identify where the review took place.
7. Record the 'Provider Discovery Review Date'. This date is important for tracking your reconsideration request against the original review.
8. Write the name of the Delmarva reviewer who conducted the original review in the designated field.
9. List the 'Name of Service(s) and Recoupment Standard(s) for which Reconsideration is being requested'. Be specific for clarity in your request.
10. Attach 'Documentation' that supports your Reconsideration Request. Ensure all relevant documents are included.
11. Provide the 'Name of Person to Contact / Phone Number'. This allows for follow-up questions and communication regarding your request.
12. After filling out all fields, review your information for accuracy, and ensure all required fields are complete.
13. Save your changes, then download, print, or share the completed form as necessary to submit your Reconsideration Request.

Take the next step in your process by completing the Reconsideration Request Form online today.