Fair Hearing Request Form printable pdf download

OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

OFFICE OF ADMINISTRATIVE HEARINGS

Website:

FAX to: (518) 473-6735

Telephone #: 1-800-342-3334

FAIR HEARING REQUEST FORM – FAX OR MAIL

P.O. BOX 1930

ALBANY, NY 12201-1930

Please Print Information Clearly. Correct and Complete Information Will Permit Us to Promptly Schedule a Fair Hearing.

CASE NAME: __________________________________________________________ _________________________________ ________

(LAST)

(FIRST)

(MI)

STREET ADDRESS: _____________________________________________________________________________ APT #: _____________

CITY: ________________________________________________________ STATE: _____________

ZIP CODE: ____________________

PHONE #: ( _______) ____________________________ DATE OF BIRTH : ___________________

SS#: ________________________

MALE

FEMALE

CASE #: ___________________ CIN #: ___________________

LOCAL AGENCY/CENTER: ___________

INTERPRETER NEEDED? YES

LANGUAGE: _________________________________________________

NO If yes, provide medical documentation. Do not delay request while obtaining medical.

Is Appellant homebound?

YES

A phone number for representative or requester is required if you don’t have a phone.

Representative

Requester

NAME: ___________________________________________________________________

ADDRESS: _______________________________________________________________________________________________________

CITY: __________________________________ STATE: _______ ZIP: __________ PHONE #: (_______) __________________________

DID APPELLANT RECEIVE A NOTICE FROM THE LOCAL SOCIAL SERVICES DEPARTMENT?

YES

(***** PLEASE ATTACH A COPY OF THE NOTICE WITH THIS FORM *****)

If Yes: Date of Notice: ______________ Effective Date: ________________ Notice #: ________________ RTI #: __________________

RESTRICTIONS

LOCAL AGENCY ACTION

CATEGORY OF ASSISTANCE (definitions below box)

Put an X in days or times

SNA

SNAP

HEAP

PCS*

OTHER

you cannot attend hearing

Discontinuance

Reduction

AM ___ ___ ___ ___ ___

Denial

PM ___ ___ ___ ___ ___

Inadequacy

(Must provide a reason)

* If Personal Care Services: Provide CASA # _______/Agency ________ & indicate type of service: _______

Name of Managed Care Plan ______________________________________________________

FA = Family Assistance (former ADC)

SNA = Safety Net Assistance (formerly HR)

SNAP = Supplemental Nutrition Assistance Program (formerly Food Stamps)

MA = Medicaid

HEAP = Home Energy Assistance Program

PCS = Personal Care Services

Reason for requesting hearing (indicate time frames):

Information needed for Foster Care hearings: Child’s name, child’s date of birth, birth mother’s name, child’s case number, agency’s name.

Indicate period seeking foster care payments.

TODAY’S DATE: __________________________

Revised 8/29/12

Fair Hearing Request Form

Related Articles

Related forms

Related Categories