Appeals - Appeal Request

Iowa Department of Health and Human Services

Appeal and Request for Hearing

Who is the appeal for?

First Name

Middle Initial

Last Name

Mailing Address (include apt, unit or lot number, if applicable)

City

State

Zip Code

Phone Number Receive SMS (Text) Messages

Other Phone Number, if applicable

Email Address

Date of Birth

Address County

Case or Account Number, if known

Your Signature

Date

What are you appealing?

Check the programs you want to appeal:

Tell us why you are appealing:

Do you want your benefits to continue during your appeal?
(You may have to pay them back, if you lose your appeal.)

Yes No

Do you want an informal conference with your worker?

Yes No

Do you need help with your appeal because you are blind or hard of hearing?

Yes No

Do you want a language interpreter for your hearing?

Yes No

If yes, what language?

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.

Do you want someone you know to help you with your appeal?

Yes No

Do you have papers showing a court has appointed this person to act for you?
You may be asked to provide a copy of these papers, if needed.

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.

First Name

Middle Initial

Last Name

Mailing Address (include apt, unit or lot number, if applicable)

City

State

Zip Code

Phone Number Receive SMS (Text) Messages

Other Phone Number, if applicable

Email Address

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.

Do you want to add a Representative?

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.

First Name

Middle Initial

Last Name

Mailing Address (include apt, unit or lot number, if applicable)

City

State

Zip Code

Phone Number Receive SMS (Text) Messages

Other Phone Number, if applicable

Email Address

Signature of Requestor

Date

Authorization to Add Representative

Appellant Name

Appellant Signature

I attest that I give permission to allow my representative to help me with my appeal and that I completed the Signature of Appellant section of this form. This includes filing an appeal with the Iowa Department of Health and Human Services (Iowa HHS) on my behalf. This person may share information about my family or me. I will not hold this person liable for giving information, even if it is confidential. This authorization will automatically stop at the end of the appeals process or earlier if I revoke this permission in writing.

First Name

Middle Initial

Last Name

Signature of Appellant

Date

Representative Signature

I attest that I agree to act as the appellant’s representative for this appeal and that I completed the Signature of Representative section of this form. I agree to abide by relevant state and federal laws concerning conflicts of interest and confidentiality of information.

First Name

Middle Initial

Last Name

Mailing Address (include business name or apt, unit or lot number, if applicable)

City

State

Zip Code

Phone Number Receive SMS (Text) Messages

Other Phone Number, if applicable

Email Address

Signature of Representative

Date

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Confirmation #

Status

In Process

Submitted Date