If you have any questions, call (360) 407-2700 or (800) 583-8271 OAH may take online hearing requests for: Food assistance Temporary Assistance for Needy Families (TANF) Community Options Program Entry System (COPES) Developmental Disabilities Administration (DDD/DDA) Medical Assistance Transfer (MAT) Vocational Rehabilitation (DVR) If your hearing is about something else, please call (360) 407-2700 or (800) 583-8271. Note: If you are being evicted from a medical facility, please fill out the medical hearing request form or call (360) 407-2700 or (800) 583-8271. Full Name First Name Last Name Email Phone Address Street Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code Enter Community Service Office (CSO) Enter DSHS or HCA Client ID Number Care providers: If care hours were reduced, please note that a provider is not allowed to request an appeal. Appeals are only available to the person receiving the benefits. Are you entering this form for someone else? Yes No Name of person completing form Relationship to appellant Note: a doctor may not enter this form for the appellant. Are you representing the appellant? Yes No Are you an attorney? Yes No Representative Name First Name Last Name Representative Address Street Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code When did you receive the decision you wish to appeal? What were you denied or what do you disagree with? If you are receiving medical benefits, are they being terminated or reduced? Yes No Are you receiving continued assistance? Yes No Are you requesting your assistance continue at the same level while waiting for your hearing? Yes No Do you need an interpreter for the hearing? Yes No What language do you need? Do you have any concerns that you will be unable to participate in the hearing due to a disability? Yes No What are your disability concerns? Please note that anything submitted past 5:00 PM (Pacific Time) is not considered filed until the following business day. Submit Leave this field blank
