Hearing request HCA Form

Medical practitioners must not complete this form on behalf of a patient unless you are representing them or have their expressed approval. 

What if I have documents to submit?  Tell the judge at your prehearing conference that you have documents you want to submit.  The judge will give you instructions on how to submit documents and the types of documents to submit.

If you have any questions, call (360) 407-2700 or (800) 583-8271.

Applicant’s or Recipient’s Full Name
Address
Are you entering this form for someone else?

IMPORTANT: Medical practitioners cannot complete this form unless you are representing the patient or have their express permission.
Are you representing the appellant?

Unless you are the parent of a child under 18 years of age, you will need to provide documents showing you are authorized to represent the appellant. Some examples of documents you can submit are:

After submitting the request for hearing, you can email those forms to oahcsc@oah.wa.gov

Representative Name
Representative Address
If you are appealing the denial of a medication, please include the name of the medication. If appealing a denial for prior authorization regarding a medical procedure, please specify what the procedure was for, such as “knee surgery”. Please state if you are receiving benefits from the Family Planning Only program and are appealing a decision from that program.
If you received a denial notice or letter, who sent you or your physician that denial?
Managed Care Organization

If the denial is from a Managed Care Organization, select the Managed Care Organization that sent you the denial notice or letter.
Does your denial notice or letter require you to file an internal appeal with your Managed Care Organization first?
Have you filed an internal appeal with your Managed Care Organization?
(For example: TANF, Food Stamps, etc.)
Do you wish to file an appeal against the additional benefits being reduced or terminated?
If you are receiving medical benefits, are they being terminated or reduced?
I want to continue assistance during the appeal before OAH, if I am eligible.
Are you receiving continued benefits?
Are you requesting your benefits to continue at the same level while waiting for your hearing?
Expedited Hearing

Note:  For certain critical medical issues or if you are being evicted from a care center, your hearing could be expedited.  If you would like your hearing expedited, please answer all of the following questions. You will need to immediately submit supporting medical documents for your expedited hearing. This can be medical records, doctor notes, etc. You can submit your supporting documents by email to asc-oah@oah.wa.gov or call (360) 407-2700 or (800) 583-8271.

Do you need an expedited hearing (that is, scheduled quickly)?
Do you have documentation to show your urgent health care need (i.e., medical records, doctor's note, etc.)?
Have you scheduled an appointment with a provider?
Is this the first available appointment?
Do you need an interpreter for the hearing?
Do you have any concerns that you will be unable to participate in the hearing due to a disability?
Have you received an eviction notice from a care facility?

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