S02 - Attachment N Denial Letter.pdf

HUD-VASH DENIAL LETTER

Date of Screening: ____________

Name: _____________________________________________________

Screened by: ________________________________________________

Thank you for your interest in the HUD-VASH program. We regret to inform you that you are not eligible at this time due to one or more of the following reasons:

☐ - Not Homeless

☐ - Not chronically homeless

☐ - Not healthcare eligible

☐ - Residing in an institutional setting for over 90 days

☐ - No need for case management

☐ - Other reasons:

You may have been denied on the basis of information in the medical chart, information obtained from other sources, and/or information provided by you during this screening.

If you have been denied, you have a right to file an appeal within 60 days from the receipt of this notice regarding the nature of this information and/or the basis of its inaccuracy or incompleteness. Please call 310-478-3711 ext. 44904 to request appeal.

You may be eligible for the following programs below (see attachment).

Referred to: ___________________________________________________________

Disposition: ___________________________________________________________

☐ - Accepted Referral

☐ - Declined Referral