• If you plan to attach supporting documents such as copies of denials, letters or bills, save the documents on your computer before you complete the form.
• The maximum file size for supporting documents is 25MB (approximately 100 pages or more).
• The system will accept most file formats such as Word, Excel, PDF, or JPG. It will not accept sound or video files or emails. If you wish to submit a copy of an email message, copy and paste the email message into a Word file.
• You should print a copy of your form before submitting. Once you submit your form, you will not be able to print a copy. You may need to adjust your margin settings before printing. Preview your form before printing.
• Your browser needs to have Javascript enabled. The form may not function properly if Javascript is not enabled. Your browser currently has Javascript enabled.

If you have technical difficulties completing this form, please contact wpso@dmhc.ca.gov for assistance.