H2O Grievance & Appeal Submission
Your Name
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Your Email Address
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Your Phone Number
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Are you submitting this form on behalf of yourself or someone else?
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Select Option
Self
Someone Else
Name of the Member
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Date of birth of the member who is impacted by this grievance or appeal
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What is your relationship to the member (person determination is for)?
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Select Option
Advocate
Designated Representative
Family Member
Guardian
Probation/Parole Officer
Other
Description of Appeal or Grievance (Please include dates, names or any other attempts to resolve the issue)
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What solution do you want?
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Continuation of services
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I am requesting that the services I am appealing be continued during the appeal process. I understand that if I lose my appeal, I may be required to pay for the cost of the services that were continued during the appeal process.
I do not want the services I am appealing to be continued during appeal process
Appeal Received Date:
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