TX HHS Form 8625-M. Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Medicaid Decision
The TX HHS Form 8625-M, "Designation of a Long-Term Care Ombudsman as Representative and Request to Appeal a Medicaid Decision," is a crucial document for nursing facility or assisted living facility residents who want to request a hearing to appeal a Medicaid decision. This form allows the resident to designate a long-term care ombudsman as their representative, ensuring they receive proper representation throughout the appeals process.
This form is typically used in situations where a resident disagrees with a Medicaid decision and wants to request a hearing to resolve the issue. The form requires the resident or their designated representative to provide specific information, including the resident's name, address, date of birth, and social security number. The ombudsman must also submit this form by emailing it to [email protected] or faxing it to 866-559-9628, along with any supporting documentation, such as the reason for appealing the decision and a request for accommodation at the hearing.
Key features of this form include the requirement for the resident or their designated representative to provide specific information about themselves and the ombudsman they are designating. The form also outlines the responsibilities of the ombudsman, including representing the resident throughout the appeals process and submitting any supporting documentation. By using this form, residents can ensure that their voices are heard and their interests are represented in the Medicaid appeals process.
- This form is used by nursing facility or assisted living facility residents who want to request a hearing to appeal a Medicaid decision.
- The form requires the resident or their designated representative to provide specific information, including their name, address, date of birth, and social security number.
- The ombudsman must submit the form by emailing it to [email protected] or faxing it to 866-559-962