Request for Redetermination Instrument Scope

Request for Redetermination Instrument

Name of Instrument

Request for Redetermination

Scope of Instrument

This instrument collects:

• Personally identifiable information from the individual submitting request

• Relevant facility information

• Relevant information necessary to approve or deny a request for redetermination

Example of DHS Forms used within the scope of this instrument

Attached is DHS Form 9037 that is used to standardize the collection of information within this instrument. DHS Form 9037 identifies most, but not all of the data routinely collected under this instrument.

1