Medicaid FAMIS Appeal Request Form - dmas virginia 2025

1. Click ‘Get Form’ to open the Medicaid FAMIS Appeal Request Form in the editor.
2. Begin by entering the Last Name, First Name, and Middle Initial of the Medicaid/FAMIS applicant. Fill in the mailing address, including city, state, and zip code.
3. Provide the Date of Birth, Gender, Social Security Number, and Health Care Number. Ensure all personal information is accurate for processing.
4. Indicate your Medicaid/FAMIS Case Number and provide primary and alternate telephone numbers along with an email address for communication.
5. Attach a copy of the denial letter or notice regarding the action you are appealing. Clearly state the agency name and date of notification.
6. Select the appropriate checkboxes that describe your appeal situation. Write a brief statement explaining why you are requesting an appeal.
7. Complete any additional sections regarding language preferences and contact methods. If applicable, provide representative details if someone else will assist you during this process.
8. Finally, ensure that the form is signed by the adult client before submitting it via mail or fax to the Appeals Division as instructed.

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