Use the
Individual Eligibility Review (IER) form to appeal a disenrollment or denial of eligibility from a financial assistance program, or to request a waiver or reduction of co-pays, fees or charges. This form, along with a
Patient Financial Worksheet and other supporting documents, must be completed and returned within 60 days of receiving written notice indicating the disenrollment or denial, or within 60 days of receipt of the bill for the fees, co-pays or charges.
Use the
Eligibility and Financial Review Committee (EFRC) form to appeal the Individual Eligibility Review (IER) decision regarding a disenrollment or denial of eligibility from a financial assistance program, or a denial of a waiver or reduction of co-pays, fees or charges. This form must be completed and returned within 60 days of the IER decision letter.