Appeal Form

Your Name

Applicant Name

Your Email Address

Your Phone Number

City

State

Zip Code

Street

Applicant Date of Birth

Is the applicant incarcerated Select Option Yes No

What is your relationship to the applicant (person the determination is for)? Select Relationship Self Advocate Attorney/Representative for Provider AZ Center for Disability Law AZ Department of Economic Security AZ Department of Juvenile Corrections Designated Representative Family Member Guardian Other Probation/Parole Officer

Options For Continued Services* Select Option I want to continue services I do not want to continue services

What are you appealing?

What solution do you want?

Submit

*For members with a Serious Mental Illness designation, your services under appeal will be continued during the appeal process, unless doing so poses a serious threat or harm to you or others. For appeals relating to Title XIX (19) or Title XXI (21) services, you may be required to pay for the cost of services that were continued during the appeal process, should you lose your appeal.