Get Dmap 3302

The Dmap 3302 form is essential for individuals requesting an appeal or hearing regarding medical assistance program decisions. This guide will help users navigate the form effectively, ensuring all necessary information is accurately provided.

Follow the steps to complete the Dmap 3302 form online.

1. Click ‘Get Form’ button to access the Dmap 3302 and open it in your online editor.
2. Fill in your personal information. Ensure you provide your full name, address, city, state, ZIP code, phone number, date of birth, and preferred language. This information helps in identifying your case correctly.
3. Indicate your request. Check all applicable boxes to indicate whether you want to appeal the decision with your Coordinated Care Organization or request a hearing through the Division of Medical Assistance Programs.
4. Provide the date of notice from which you are requesting an appeal or hearing. This date is crucial for determining deadlines.
5. Specify if you wish to continue receiving services during the appeal or hearing process by selecting the appropriate option.
6. Determine if an expedited process is required. If you believe a delay would cause serious harm, check the yes box and provide a brief explanation.
7. If applicable, provide the details of any representative helping you with the appeal or hearing. Include their name, address, and phone number.
8. Explain why you believe the service should be covered, providing any supporting information or documentation that may assist your case.
9. Sign and date the form. If someone filled out the form for you, they should include their name and relation to you.
10. Print or download a copy of your filled form for your records. Submit the completed form as directed on the document.

Complete your Dmap 3302 form online today to ensure your appeal or hearing request is submitted promptly.