Redetermination: First Level Appeal Form

Palmetto GBA is providing a Redetermination: First Level Appeal form for providers to use. While not required, this form may make submitting your redeterminations easier. The form includes all of the required elements for making a valid request, and it will ensure that your request is directed to the proper area once received in our office.

Please submit redetermination requests separately and avoid stapling multiple redetermination requests together.

You can download the form and type your information directly onto it. After you complete the form, it still needs to be printed and mailed to us. To access this form, please visit our forms web page.