Appeal And Hearing Request Page 2
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46. I have a lawyer, advocate, friend or representative who will help me with my Appeal or Hearing
(send your request in as soon as possible, you can choose someone any time before the
Hearing):
No, I am representing myself.
Yes, Name:
Address, City, State, ZIP:
Phone:
7. I believe you should cover this service because (you or your doctor can also send documents that
support your case):
8. Signature – If someone filled the form out for you, have them sign it.
Representative’s Name (if someone filled out this form for you):
Member (or Representative’s) Signature:
Relation to person named in this letter:
Self
Parent
Other
Date:
Member’s Social Security number:
The Oregon Health Authority is authorized to request your Social Security Number under 42 USC
1320b-7(a) and (b), 7 USC 2011-2036, 42 CFR 436.920, 42 CFR 457.340(b). Your SSN will be
used to locate your file and records. Providing a Social Security Number is voluntary.
Send this form:
To request an Appeal – Your CCO or Plan at the address shown on the Notice of Action
To request a Hearing – OHA-DMAP Hearings, 500 Summer St NE, Salem, OR 97301-1077,
FAX: 503-945-6035
To request both an Appeal and a Hearing – OHA-DMAP Hearings, 500 Summer St NE, Salem,
OR 97301-1077, FAX 503-945-6035
DMAP 3302 (Rev 1/2014)
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