Request For A Fair Hearing - Oklahoma Department Of Human Services
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2*13MP001E-001*
*13MP001E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES
Request for a Fair Hearing
Return this form to your worker.
Notice:
This form must be returned to your local OKDHS human services center
(HSC) by either:
• 10 days from the date OKDHS mails this form to you, or gives this form to you;
• 30 days from the date of the notice you are appealing; or
• whichever date is later.
If you are getting assistance payments or services, to keep your benefit while the
appeal is pending, follow the instructions in the Important notice section on page two.
The HSC staff completes this section before Form 13MP001E is given to client:
County name and number
Case name
Case number
Date client first indicated he or she wanted a hearing, orally or in writing:
Is this request timely, as defined by OKDHS policy?
Yes
No
Food stamps - 90 days from notice. All other programs - 30 days from notice.
Date Form 13MP001E given to client
Date HSC received Form 13MP001E
Worker name and number OR local nurse name, number, and location
Supervisor name and number OR area nurse name, number, and location
Attach notice being appealed for Appeals Unit. If none attached, explain:
Issue being appealed:
Revised 7-15-2008
13MP001E (H-1)
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