Hearing Request Public Assistance Form

Hearing Request Form - Public Assistance
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
Area CodePhone Number

Address

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 a

Attorney
Non attorney
Representative Name

First Name
Last Name

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.

Hearing Request Form - Public Assistance