Request appeal 2026

1. Click ‘Get Form’ to open the request appeal form in the editor.
2. In Section 1, provide your personal information as the appellant. Fill in your name, date of birth, address, and daytime phone number. If other household members are appealing, list their names and dates of birth.
3. Move to Section 2 and indicate why you are appealing. You can check multiple reasons based on your eligibility determination notice.
4. If applicable, use Section 3 to provide additional details about your appeal. This section is optional but can strengthen your case.
5. In Section 4, if you need an expedited review due to urgent health needs, check the box and explain your situation.
6. Finally, in Section 5, sign and date the form. Ensure all adult household members listed also sign to consent to information sharing.

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