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  • Va Medicaid/famis Appeal Authorized Representative Form 2019

Get Va Medicaid/famis Appeal Authorized Representative Form 2019

VIRGINIAMEDICAID/FAMISAPPEAL AUTHORIZEDREPRESENTATIVEFORM AppellantInformation Name: DateofBirth: SocialSecurity#: Medicaid/Miscast#: PhonewithAreaCode:() Understand: Icanrepresentmyself ThisauthorizationisvoluntaryandIhavetherighttorefusetosignorcancelitatanytime.

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Contact support

Send the Virginia Medicaid and FAMIS Appeal Request Form or appeal request letter and related documents, including the notice of action you are appealing to: Department of Medical Assistance Services Appeals Division 600 East Broad Street Richmond, Virginia 23219 Or fax: (804) 452-5454.

You must file an appeal with DMAS within 120 days of receiving a final decision from the MCO (as opposed to 30 days) and the 120 days cannot be extended.

For assistance with billing, claims, member eligibility, memos and other regulations, call the Virginia Medicaid Provider Helpline at the toll-free (800-552-8627) or in-state (804-786-6273) phone numbers.

As a result of eligibility expansion, Medicaid is available to Virginia adults under age 65 who earn up to 138% of the poverty level. In 2023, that's $20,120 for a single person, and about $34,307 for an adult in a household of three people).

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Get VA Medicaid/Famis Appeal Authorized Representative Form
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
VA Medicaid/Famis Appeal Authorized Representative Form
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