Appeal And Hearing Request
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4DIVISION OF MEDICAL ASSISTANCE PROGRAMS
Medical Assistance Programs Service Denial
Appeal and Hearing Request
Oregon Health Authority (OHA) completes this part if a hearing is requested
Client ID
Case #
Branch #
Worker ID
Program #
Reference # (if plan referral)
Member or Member’s Representative completes this part
Complete pages 1 and 2 of this form.
Return the form to the address listed on page 2.
1. Member name:
Member ID#
Address:
City:
State:
ZIP code:
Phone Number
Date of Birth:
My language is:
English
Spanish
Russian
Vietnamese
Other:
2. I want
check all that apply. See page 3 for information about Appeals and Hearings.
To Appeal the decision shown in the Notice of Action with my Coordinated Care
Organization (CCO) or Managed Care Plan (Plan).
A Hearing through the Division of Medical Assistance Programs (DMAP) on the decision
shown in the Notice of Action or Notice of Appeal Resolution.
3. Date of Notice for which I am requesting an Appeal and/or Hearing (as shown on the Notice of
Action or Notice of Appeal Resolution):
4. I am getting this service now and I want to keep getting it during the Appeal and/or Hearing
process:
No
Yes (read the Continuing Services section on page 4 of this form before checking this box)
5. I need an expedited (fast) Appeal and/or Hearing because I have a condition which is an
immediate, serious threat to my life or health and I would be harmed by waiting.
No
Yes, I want an expedited (fast) Appeal/Hearing. Please explain how you would be harmed by
waiting.
DMAP 3302 (Rev 1/2014)
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