This form is used by workers to report suspected provider or recipient related errors to the Surveillance Utilization Review (SURS) Unit who wish to request a hearing.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

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Axiom
North Dakota
Manual
HHS
ACA Medicaid
510 03 100 30
Block 1

SFN 20, “Surveillance & Utilization Review Section (SURS) Referral” 510-03-100-30

Official source

(New 7/1/2014 ML #3404)

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This form is used by workers to report suspected provider or recipient related errors to the Surveillance Utilization Review (SURS) Unit who wish to request a hearing.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms .

in view

Whole section