This form is for providers of WA Cares services or provider applicants. Legal Name Legal First Name Legal Last Name Business Name, if applicable Phone Email WA Cares ID Number 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 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 A representative can be a friend, family member, or an attorney. If the representative is an attorney, they should file a Notice of Appearance with the Office of Administrative Hearings. 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 Representative Phone What is the date of the decision you wish appeal? On what date did you receive this decision? Why do you disagree? (Please provide specific information about the reason(s) you are requesting an appeal) If you need an interpreter for the hearing, what language do you require? Do you need an interpreter for the hearing? Yes No What language do you require? If you have any concerns that you will be unable to participate in a hearing by telephone, due to a disability, please explain: 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. Submit Leave this field blank
