Get Va Medicaid/famis Appeal Authorized Representative Form

Filling out the VA Medicaid/Famis Appeal Authorized Representative Form online is an important step in ensuring that your appeal is properly submitted. This guide provides clear, step-by-step instructions to help users navigate each section of the form confidently.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Enter the client’s name and social security number (SSN) in the designated fields. Ensure that this information is accurate as it will be used to identify your case.
3. Fill in the date of birth and case number. The date of birth should be written in a month/day/year format. The case number can usually be found in any previous correspondence from the agency regarding your benefits.
4. Provide your area code and daytime phone number. This information is critical for the agency to contact you regarding your appeal.
5. Indicate the agency to which you are appealing by specifying the name of the agency that made the decision to deny, terminate, or reduce your Medicaid or FAMIS benefits.
6. Write the date when the action was taken. This helps establish a timeline for your appeal.
7. Appoint an authorized representative by writing their name in the designated field. This person will act on your behalf throughout the appeal process.
8. Fill in your authorized representative’s address and daytime phone number. This is important for communication concerning the appeal.
9. Read the statements about your rights. You must acknowledge that signing this form is voluntary and that it does not waive your right to represent yourself.
10. Provide your signature and the date. If the appellant is a minor, use the parent or guardian's name and signature.
11. If the appellant is physically unable to sign, the authorized representative may sign on their behalf. Ensure to describe the physical incapacity in the provided field.
12. Finally, save the changes made to the form. You can then download, print, or share the completed form for submission.

Complete your VA Medicaid/Famis Appeal Authorized Representative Form online today to ensure your appeal is processed promptly.