Dismissal form template: Fill out & sign online

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Click ‘Get Form’ to open the dismissal form in the editor.
Begin by entering the MAXIMUS CASE NUMBER at the top of the form. This is essential for tracking your case.
Select the CASE PRIORITY from the options provided: Expedited, Standard Service (Pre-service), or Standard Claim (payment).
Fill in the DATE(S) OF SERVICE IN QUESTION to specify when the services were rendered.
Choose a reason for dismissal from the PLAN’S DISMISSAL REASON section, ensuring you check all that apply.
Complete the ENROLLEE DATA section with accurate information about the enrollee, including name, HIC, address, and phone number.
Indicate if a Dismissal Determination Notice is required in a language other than English by selecting 'Yes' or 'No'. If 'Yes', specify the language.
In REQUESTOR DATA, identify who is requesting the dismissal review and provide their contact details.
Fill out MEDICARE HEALTH PLAN (MHP) DATA with relevant plan information and contact details for correspondence regarding this dismissal review.
Finally, complete the DISMISSAL CASE FILE NARRATIVE section by summarizing key points and justifications related to your case.

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