| Reason | [field-value] | Prior Appeal Case | [Case Reference No.] |
|---|---|---|---|
| Receipt Method | [field-value] | Emergency | [field-value] |
| Effective Date | [Date] | Deadline Date | [Date] |
| Timely | [True] | Continue Benefits | [True] |
| Receipt Acknowledged | [True] | Appealed Status | [field-value] |
Comments
| [Comments] |