Notice of Claim Reconsideration CalPERS Long-Term Care Program 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information. Fill in your last name, first name, middle initial, address, city, state, ZIP code, and phone number clearly.
3. If you have a representative assisting you, complete their information in the designated section with the same details: last name, first name, middle initial, address, city, state, ZIP code, and phone number.
4. Prepare a letter of request for reconsideration. Clearly state the action taken by the Program that you wish to be reconsidered and provide the date of that decision. Include your reasons for believing the decision was incorrect.
5. Attach any relevant medical records or other documentation that supports your request for reconsideration.
6. If applicable, complete and attach the authorization form to allow someone else to assist you with this process.
7. Sign and date the form before submitting it via mail or fax to CalPERS Long-Term Care Program at the provided address.

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