If you have any questions, call (360) 407-2700 or (800) 583-8271. Full Name First Last Phone Email Date of Birth Address Street Address City/Town State/Province - Select -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 ZIP/Postal Code Country Enter DSHS or HCA Client ID number Are you entering this form for someone else? Yes No Name of the person completing form Relationship to appellant Are you representing the appellant? Yes No 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: Notice of Appearance (NOA) for attorneys only Power of Attorney (POA) Proof of Guardianship HCA Authorization for Release of Information form After submitting the request for hearing, you can email those forms to oahcsc@oah.wa.gov Representative Name First Name Last Name Representative Address Street Address City/Town State/Province - 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 ZIP/Postal Code Country When did you receive the decision you wish to appeal? When did you receive the decision you wish to appeal? Benefits at Issue What were you denied and why do you disagree? Are there any other benefits being terminated or reduced at this time? (For example: TANF, Food Stamps, etc.) Do you wish to file an appeal against the additional benefits being reduced or terminated? Yes No If you are receiving medical benefits, are they being terminated or reduced? Yes No Are you receiving continued benefits? Yes No Are you requesting your benefits to continue at the same level while waiting for your hearing? Yes No 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. Do you need an expedited hearing (that is, scheduled quickly)? Yes No Please state the reason you need an expedited hearing and how quickly you need it. What is your urgent health care need? Do you believe that your life, health or ability to attain, maintain, or regain maximum function will be impaired if you have to wait for a hearing (four to six weeks)? Do you have documentation to show your urgent health care need (i.e., medical records, doctor's note, etc.)? Yes No If yes, please email the documents to oahcsc@oah.wa.gov. If you cannot email them, please call OAH at 800-583-8271 or 360-407-2700. Have you scheduled an appointment with a provider? Yes No If yes, when is the appointment? Is this the first available appointment? Yes No Have you been prevented from scheduling an appointment due to lack of coverage? Do you need an interpreter for the hearing? Yes No What language do you need? If you need an interpreter for the hearing, what language do you require? Do you have any concerns that you will be unable to participate in the hearing due to a disability? Yes No If you have any concerns that you will be unable to participate in the hearing due to a disability, please explain: Have you received an eviction notice from a care facility? Yes No Eviction Date Name, address and phone number of the facility If you would like OAH to email this request for hearing to you or someone else, please provide the email address(es) below. (If more than one email address, separate by a comma (,)) Please note that anything submitted past 5:00 PM (Pacific Time) is not considered filed until the following business day. After submitting the request for hearing, you can email supporting documents to oahcsc@oah.wa.gov. Please be sure to include your name and client ID on the documents. Submit Leave this field blank
