Iowa Department of Health and Human Services

Appeal and Request for Hearing

Who is the appeal for?

What are you appealing?

Check the programs you want to appeal:

Yes  No
Yes  No
Yes  No
Yes  No

Someone to help you

You can have someone help you with your appeal. You do not have to list someone here. (If you are appealing child abuse or adult abuse, then only an attorney can help with your appeal.)

This person will get copies of all appeal documents, which may include access to your protected health information. This person must agree to abide by relevant state and federal laws concerning conflicts of interest and confidentiality of information.
Yes  No
Yes  No
I authorize the following person to act on my behalf during my appeal. This authorization will automatically stop at the end of the appeals process or if I revoke this permission in writing.

Requestor Information

If you filled out this form on behalf of someone else, please provide the following information and complete the Authorization to Add Representative form. To use the form electronically, answer "yes" to the next question.
Yes  No
If the appeal relates to a decision made by a managed care organization, you also need to provide a completed form 470-5526, Authorized Representative for Managed Care Appeals.


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