HRD Appeals Submission Form

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Please fill out the following form as completely as possible to initiate your appeal with the Health Regulation Division.

Appellant Name:

Appellant Identity:

Contact Information:

Phone

Mailing Address

Are you represented by an attorney?

Yes

Please provide the attorney’s contact information:

Name

Phone

Type of Appeal:

Facility/License Type:

Facility/Licensee Name:

HFID:

License #:

Project/Report #:

Please identify the deficiencies you are disputing by tag number separated by a comma (e.g., 0625, 2165):

Description of your appeal:

Background Study #:

Upload file(s):