DMAS Appeal Request Form

Use this process to generate a DMAS Appeal Request Form.

Process Steps:

Navigate to the DMAS Appeal Request Form page through the Search Case Information and Search Document Information pages. The DMAS Appeal Request Form page displays.

In the Appeal Request Information section:

- Enter Case DOB.
- Chose appropriate Case Gender radio button (required).
- Enter in Medicaid / FAMIS number.
- Enter in SSN.
- Enter Primary Telephone.
- Enter Alternate Telephone.
- Enter Case Email.
- Enter Case Fax.

Click Preview to view a PDF preview of the form.

The selected form displays in a pop-up window as a PDF file and is auto-populated with the information previously entered into the VaCMS.

Click the print icon in the upper left corner of the PDF to print the form.

Click X in the upper right corner of the PDF to close the pop-up window.

Click Submit to send the form to be printed.

Results of the Procedure:

The DMAS Appeal Request Form is generated.

Updated 04/25/2016