Form CMS-10520 Vendor Appeal Form

Qualified Health Plan Enrollee Experience Survey

REQUEST FOR APPEAL
Organization Name:

Date Submitted:

Address:
Primary Contact:
Telephone:

Title:
E-mail:

Please provide new or additional information in the Response Section(s) below for each
Criterion Not Met that is being appealed.
Criterion Not Met:

New or Additional Information:

Justification for Exclusion from Participation Form:

Criterion Not Met:

New or Additional Information:

Justification for Exclusion from Participation Form: