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USHS APPEAL REQUEST Client Name: _________________________
CSP#_________________________ Date: ________
Date of Denial: ________________________ Reason for Denial: ____________________________________________________________________ Request for denial reversal: (Provide statements and documentation supporting request) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Provider Agency Staff Member: ___________________________________ Date: ________________ Provider Agency Staff Member: ___________________________________ Date: ________________
CSB USE ONLY: ☐Approved
Date of Decision: ______________
☐Denied Explanation of decision: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ CSB Staff Member: ______________________________________ Date: ________________ CSB Staff Member: ______________________________________ Date: ________________
USHS Appeal Request.docx
