Fillable Appeal Request Form Appellant Information (Washington Health Benefit Exchange)

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Appeal Request Form Appellant Information (Washington Health Benefit Exchange)

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HBE 13-001
(Rev. 09/2015)
Questions? WAHBE Appeals Program appeals@wahbexchange.org 1-855-859-2512 1
?
Appeal Request Form
You can request a hearing with a judge, if you think we made a mistake about you or your family members’ eligibility. By
filling out this form, you are requesting a hearing with a judge. Requesting an appeal is time sensitive! Be sure you
send this form in less than 90 calendar days from the date on the eligibility notice that you are disputing.
Application ID
Today’s date (mm/dd/yyyy)
Date on eligibility notice
Appellant Information
(An “appellant” is the person requesting an appeal. The appellant should be the primary applicant on your Washington
Healthplanfinder application.)
First name
Middle initial
Last name
Date of birth (mm/dd/yyyy)
Daytime phone number
( )
Email address
Street address
Apt./Ste. #
City
Zip code
What is the best way to contact you?
Email
Telephone
Mail
Reasons for Filing an Appeal Mail Appeal to:
Healthplanfinder eligibility for or the amount of:
• Health Insurance Premium Tax Credit
• Cost Sharing
• Special Enrollment Period
Washington Health Benefit Exchange
Appeals
PO Box 1757, Olympia, WA 98507-1757
Fax: 360-841-7653
Questions: 1-855-859-2512
Washington Apple Health (Medicaid) eligibility.
I w
ould like to keep my Washington Apple Health
coverage during the appeals process.
Washington Apple Health
PO Box 45504, Olympia, WA 98504-5504
Apple H
ealth questions: 1-855-623-9357
*You must send this form within 10 days of receiving
the eligibility notice or before your coverage ends.
Briefly Explain the Reasons for Your Appeal
Why do you want a hearing?
HBE 13-001
(Rev. 09/2015)
Questions? WAHBE Appeals Program appeals@wahbexchange.org 1-855-859-2512 2
?
A
uthorized Representative (Optional)
You may have a relative, friend, legal counsel, or another spokesperson, including an authorized representative, help you
file this appeal or participate in your appeal. If you choose to name an authorized representative, you’re giving this person
permission to talk with us about your appeal.
Name of Authorized Representative (first name, middle initial, last name)
Daytime phone number
Alternative phone number
Email address
Street address
Apt./Ste. #
City
State
Zip code
Representative’s relationship to you (check all that apply)
Attorney/Legal Counsel
Employer
Family member of friend
Tribal representative
Insurance agent, broker, or navigator
Legal Guardian/Power of Attorney
Legal consultant or advocate (not an attorney)
Other:
How Can We Help?
Appeals hearings are in English, unless you request an interpreter or other accommodations.
Do you want your notices in a language other than English?
Yes
No
If yes, what language?
Do you want an interpreter at no cost?
(Friends and family members cannot act as your interpreter.)
Yes No
If yes, what language?
Do you need other accommodations or help because of a disability?
Yes No
If yes, please describe what you need:
Tribal Affiliation
Are you a member of a federally recognized tribe?
Yes
No
Is yes, what tribe?
Read and Sign Below (Required)
My signature below is my request for a hearing before a judge. I disagree with the decision about my eligibility. The
information provided in this form is true and correct, to the best of my knowledge. I understand that this appeal request
may be forwarded to the entity with the authority to handle my appeal.
Appellant signature
X
Date of signature (mm/dd/yyyy)
Request an expedited appeal. The regular appeals process takes 30 – 90 days. You may request an expedited (faster)
hearing if you have an immediate need for health services. If you request an expedited appeal, you
must also include
proof that the regular appeal process could jeopardize your life, health, or ability to maintain or regain maximum function.
Contact Appeals at 1-855-859-2512 for more information.
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Appeal Request Form Appellant Information (Washington Health Benefit Exchange)

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Completed 31 January 2021

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