If you have any questions, call (360) 407-2700 or (800) 583-8271 OAH may take online hearing requests for: Food assistance Temporary Assistance for Needy Families (TANF) Community Options Program Entry System (COPES) Developmental Disabilities Administration (DDD/DDA) Medical Assistance Transfer (MAT) Vocational Rehabilitation (DVR) If your hearing is about something else, please call (360) 407-2700 or (800) 583-8271. Note: If you are being evicted from a medical facility, please fill out the medical hearing request form or call (360) 407-2700 or (800) 583-8271. Full Name First Name Last Name Phone Email Date of Birth 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 Enter Community Service Office (CSO) Enter DSHS or HCA Client ID Number Are you completing this form for someone else? Yes No Name of 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 After submitting the request for hearing, you can email those forms to oahcsc@oah.wa.gov Are you an attorney? Yes No 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? Benefits at Issue What were you denied and why do you disagree? 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 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 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 need? If you have any concerns that you will be unable to participate in the hearing due to a disability, please explain: 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? Please note that anything submitted past 5:00 PM (Pacific Time) is not considered filed until the following business day. Email copy of this form to: (If more than one email address, separate by a semicolon (;)) After submitting the request for hearing, you can email supporting documents to oahcsc@oah.wa.gov Submit Leave this field blank
