Questions? WAHBE Appeals Program firstname.lastname@example.org 1-855-859-2512 2
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)
Representative’s relationship to you (check all that apply)
Family member of friend
Insurance agent, broker, or navigator
Legal Guardian/Power of Attorney
Legal consultant or advocate (not an attorney)
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?
Do you want an interpreter at no cost?
(Friends and family members cannot act as your interpreter.)
Do you need other accommodations or help because of a disability?
If yes, please describe what you need:
Are you a member of a federally recognized 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.
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.