Follow the steps to successfully complete your appeal form online.

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Fill in your name and the patient's name in the designated fields.
3. Indicate the name of the enrolled employee and provide the Member ID number.
4. Complete your address information, including city, state, and zip code.
5. Enter both your home and business phone numbers in the appropriate fields.
6. Detail the service or supply requested and include the date of service.
7. Provide the name of the physician, hospital, or other health care provider associated with the appeal.
8. Select one or more reasons for your appeal by checking the appropriate boxes.
9. In the designated area, describe the reason(s) you are filing this appeal in detail.
10. Clearly state the specific remedy you seek by filing this appeal.
11. Indicate whether this qualifies for an expedited appeal and if you are requesting one.
12. Attach any relevant documents that support your appeal, such as claim explanations or correspondence.
13. Address the appeal to the Director of the Department of Human Resource Management, ensuring to mark the envelope confidential.
14. Have the member sign the form or, if applicable, include the name of the authorized representative.
15. If the appeal is for medical or mental health claims, ensure a HIPAA Authorization Form is included.
16. Save your changes, then download, print, or share the completed form as needed.

Complete your VA DHRM Health Benefits Program Appeal Form online now.