PDF
Word
Form DHS-4667-ENG Prescription Drug Reconsideration Request Form - Minnesota
What Is Form DHS-4667-ENG?
This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is the DHS-4667-ENG form?A: The DHS-4667-ENG form is the Prescription Drug Reconsideration Request Form in Minnesota.
Q: What is the purpose of the DHS-4667-ENG form?A: The purpose of the DHS-4667-ENG form is to request reconsideration for prescription drug coverage.
Q: Who can use the DHS-4667-ENG form?A: Anyone in Minnesota who wishes to request reconsideration for prescription drug coverage can use the DHS-4667-ENG form.
Q: Is there a deadline for submitting the DHS-4667-ENG form?A: Yes, there is a deadline for submitting the DHS-4667-ENG form. It must be submitted within 30 days from the date of the denial notice.
Q: What information is required on the DHS-4667-ENG form?A: The DHS-4667-ENG form requires information such as the applicant's personal details, prescription details, reason for reconsideration, and supporting documentation.
Q: How long does it take to get a decision on the reconsideration request?A: The timeframe for a decision on the reconsideration request may vary, but it is typically within 30 days from the date of the form submission.
Q: Can I appeal if my reconsideration request is denied?A: Yes, if your reconsideration request is denied, you have the right to appeal the decision.
Q: Are there any fees associated with submitting the DHS-4667-ENG form?A: No, there are no fees associated with submitting the DHS-4667-ENG form.
Form Details:
- Released on May 1, 2011;
- The latest edition provided by the Minnesota Department of Human Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form DHS-4667-ENG by clicking the link below{class="scroll_to"} or browse more documents and templates provided by the Minnesota Department of Human Services.
