Hearing Request HCA MDTE Form

Phone

Area CodePhone Number

Enter DSHS or HCA Client ID Number

Name of person completing form

Are you representing the appellant?

Yes

No

Representative Address

Street Address
Street Address 2
City	State / Province
Postal / ZipCode	Country

What were you denied or what do you disagree with?

Are you receiving continued assistance?

Yes

No

Do you need an interpreter for the hearing?

Yes

No

Do you have any concerns that you will be unable to participate in the hearing due to a disability?

Yes

No

Have you received an eviction notice from a medical facility?

Yes

No

Please note that anything submitted past 5:00 PM (Pacific Time) is not considered filed until the following business day.

Note: For certain critical medical issues or if you are being evicted from a care center, your hearing could be expedited. If you believe your hearing needs to be expedited please call OAH at (360) 407-2700 or (800) 583-8271.

Washington State
Office of Administrative Hearings

Hearing Request Form - Medication, Medical Services, Medical Equipment