Attachment E, LPS UM Plan 10-2016 Request to Appeal Denial of Authorization Date of Denial____________ Request Date_______________ Decision Date______________ Record # Name of Individual Requesting/Receiving Services Provider Name Requested Service(s)
Attachment E, LPS UM Plan 10-2016 Request to Appeal Denial of Authorization Date of Denial____________ Request Date_______________ Decision Date______________ Name of Individual Requesting/Receiving Services Record # Provider Name Requested Service(s)