DHS-0033-ENG 6-22 (1.0.4)

Appeal to State Agency

Authority

Is this appeal about you or someone else?

Someone else

Usually, only the person that is the subject of the appeal may start an appeal. However, you may be able to start the appeal for them if you have a legal or other relationship with the person that allows you to do so.

If you have a document that shows your authority, send it to the Appeals Division as soon as possible. You can upload it here and submit it with the appeal request. The appeal may be delayed or dismissed if authority is not provided.

The file was not added as an attachment.

What is your authority to file an appeal for this person?

Describe your authority to file this appeal.

Is the appeal for a person or a business?

Person

Business

BUSINESS NAME

MAILING STREET ADDRESS

SUITE NUMBER

CITY

STATE

ZIP CODE

PHONE NUMBER

No phone number

Contact information

FIRST NAME

LAST NAME

TITLE

PHONE NUMBER

No phone number

EMAIL ADDRESS

Appellant

Tell us about the person the appeal is for.

FIRST NAME

MIDDLE NAME

LAST NAME

If different from your legal name, what is the name you want staff to call you?

CASE NUMBER

PMI NUMBER

DATE OF BIRTH

PREFERRED PRONOUNS

STREET ADDRESS

APARTMENT NUMBER

CITY

STATE

ZIP CODE

PHONE NUMBER

No phone number

EMAIL ADDRESS

Agency

Which agency took the action you are appealing? Was it a state agency, county, tribe or health plan? If you are not sure, look at who sent you the notice.

What is the date the notice was sent to you? This date is usually at the top of the notice.

On what date does the notice say the action will happen?

Uploading a copy of the notice with this request will help process your appeal faster.

The file was not added as an attachment.

Reason for appeal

Which program or type of benefits is this appeal about?

Please explain what the agency did that you disagree with and why you are appealing. Please provide as much information as you can.

You can upload documents you would like the human services judge to see.

The file was not added as an attachment.

Continued benefits

You may be able to keep getting your benefits at the same rate as you do now until a decision is made in the appeal. If you lose your appeal, you may have to pay back some or all of the benefits you got.

I want to keep getting benefits at the same rate as now until my appeal is decided.

I want to change my benefits to whatever the notice told me until my appeal is decided.

I am not getting benefits right now.

The appeal is not about my level of benefits.

Emergency appeal

Do you have an emergency and need a faster appeal?

Yes

Tell us more about your emergency and why it requires a faster appeal. We need this information to decide whether you qualify. For example, did you receive a utility shut off or an eviction notice? Do you need a critical medical procedure or medication? Give specific details like date of the eviction, type and reason for the medication, or what will happen if you do not get the procedure done. Only appeals with a time sensitive emergency will qualify for a faster appeal.

Access

Is an interpreter needed?

Yes

What is your preferred language?

Type in your language.

Do you need other accommodations or special arrangements?

Yes

Please explain what you need.

Representative

Is someone representing the person in the appeal? This could be an attorney, family member, friend or other advocate.

Yes

Tell us about the representative.

FIRST NAME

LAST NAME

MAILING STREET ADDRESS

APARTMENT/SUITE NUMBER

CITY

STATE

ZIP CODE

PHONE NUMBER

No phone number

EMAIL ADDRESS

Relationship to the person the appeal is about

Describe your relationship to the person

I agree to the following:

I authorize this person to represent me in this appeal.
I authorize the Minnesota Department of Human Services (DHS) and other agencies connected to this appeal to release to my representative all documents and other information about me related to this appeal. I understand that this may include private and sensitive information about me, including financial, welfare, health, mental health and chemical health information.
I know this information will be used by my representative to help me with my appeal.
I know I do not have to consent to this release of information.
I know that, generally, I must give written consent for DHS to give out the information.
I know if I do not consent, the information will not be released unless the law otherwise allows it.
I may stop this consent with a written notice at any time, but this written notice will not affect information the agency has already released.
The person or agency who gets my information may be able to pass it on to others.
If my information is passed on to others by DHS, it may no longer be protected by this authorization.
This consent will end one year from the date I sign it, unless the law allows for a longer period.

Sign and submit

The reason we are asking for this information is to help the Appeals Division process your appeal.

If you provide the data, it will be used by the Appeals Division to make sure the correct county or state agency is made a party to the appeal. It will also be used to determine if and when a hearing should occur or whether more information is needed before the appeal can go forward. The Appeals Division will also use the information you submit to determine if the agency took the correct action on your appeal. In addition, the agency whose action you are appealing will use the information to review what it did on your case. The agency will use it to prepare a response to your appeal or to try and resolve the matter with you.

You are not legally required to provide this data and may refuse to do so. However, if you do not provide the data, it may delay the processing of your appeal and the time it takes to make a decision on it.

The information you provide is private. It will not be shared with anyone who does not have a legal right to see it. For most appeals, this includes representatives from the agency whose action you are appealing, along with Appeals Division staff and other state staff who monitor and report on the program(s) under appeal. The information may also be shared upon court order or provided to the state, federal or legislative auditors. If you further appeal this decision, the information may also be shared with the district court or other entity to which you have further appealed.

By signing this form, I confirm that:

I have answered all of the questions to the best of my knowledge.
I understand that I am not required to complete this form and am voluntarily completing it for the purpose of filing an appeal.
I understand how the information I give will be used and who may have access to it.
If I named a representative, that person is authorized to represent me in this appeal and to receive all information about me related to the appeal.

ELECTRONIC SIGNATURE

TODAY'S DATE

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