Form MS406-EE "Request to Appeal Form for Denial of Leave" - Maryland

Form MS406-EE is a Maryland Department of Budget and Management form also known as the "Request To Appeal Form For Denial Of Leave". The latest edition of the form was released in April 1, 2018 and is available for digital filing.

Download a PDF version of the Form MS406-EE down below or find it on Maryland Department of Budget and Management Forms website.

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Download Form MS406-EE "Request to Appeal Form for Denial of Leave" - Maryland

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STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
REQUEST TO APPEAL FORM - FOR DENIAL OF LEAVE
(ALL FIELDS ARE REQUIRED)
NAME:
DATE:
HOME ADDRESS:
______
JOB TITLE AND SUMMARY OF DUTIES:
AGENCY NAME:
LAST DAY WORKED:
REQUEST IS FOR: EMPLOYEE
;
OR FAMILY MEMBER
My request for Employee-to-Employee leave should be reconsidered because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
In addition to submitting your appeal, please have your treating physician(s) fax or email any
additional medical records that support your Employee-to-Employee Leave Appeal.
The
medical documentation should address only the period of time you are appealing. It must
include detailed information that explains the severity and duration of your (or your family
member’s) medical condition(s).
Please refer to the State Employee-to-Employee Leave
Donation Program – Medical Documentation sheet you received with your denial letter for
examples of the types of documentation that should be provided. The appeal and the records
may be emailed or faxed. Please follow the instructions in your denial letter.
MS 406-EE
Rev. 4/2018
STATE EMPLOYEE-TO-EMPLOYEE LEAVE DONATION PROGRAM
REQUEST TO APPEAL FORM - FOR DENIAL OF LEAVE
(ALL FIELDS ARE REQUIRED)
NAME:
DATE:
HOME ADDRESS:
______
JOB TITLE AND SUMMARY OF DUTIES:
AGENCY NAME:
LAST DAY WORKED:
REQUEST IS FOR: EMPLOYEE
;
OR FAMILY MEMBER
My request for Employee-to-Employee leave should be reconsidered because:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
In addition to submitting your appeal, please have your treating physician(s) fax or email any
additional medical records that support your Employee-to-Employee Leave Appeal.
The
medical documentation should address only the period of time you are appealing. It must
include detailed information that explains the severity and duration of your (or your family
member’s) medical condition(s).
Please refer to the State Employee-to-Employee Leave
Donation Program – Medical Documentation sheet you received with your denial letter for
examples of the types of documentation that should be provided. The appeal and the records
may be emailed or faxed. Please follow the instructions in your denial letter.
MS 406-EE
Rev. 4/2018
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