If you have any questions, call (360) 407-2700 or (800) 583-8271 Full Name First Last Phone 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 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 Note: a doctor may not enter this form of the appellant Are you representing the appellant? Yes No Representative Name First Name Last Name Representative Address Street Address City 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 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? Have you received an eviction notice from a medical facility? Yes No Name, address and phone number of the 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. Submit Leave this field blank
