Hearing request HCA Form

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

Full Name
Are you entering this form for someone else?
Note: a doctor may not enter this form of the appellant
Are you representing the appellant?
Representative Name
Representative Address
If you are receiving medical benefits, are they being terminated or reduced?
Are you receiving continued assistance?
Are you requesting your assistance continue at the same level while waiting for your hearing?
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 medical facility?

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.