Request For Hearing/agency Action Form
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19/2015
REQUEST FOR HEARING/AGENCY ACTION
*Mandatory Fields. Please Print Clearly
This request must be filled out as completely as possible and filed with the Office of Administrative Hearings,
Division of Medicaid and Health Financing, WITHIN THIRTY (30) DAYS OF THE DATE A DENIAL NOTICE
IS ISSUED.
*Person Requesting Hearing: _____________________________________________*Phone #: ____________________
*Address: _________________________________________________________________________________________
Email Address: _________________________________________________________ Fax #: ______________________
*Name of Client: _________________________________________________Client I.D.#:________________________
Medicaid Provider Name:__________________________________________ Provider NPI# ______________________
*Program (check one):
Medicaid Traditional
Medicaid Non-Traditional
PCN
CHIP
Other__________
Procedure or Service Code(s): ________________________________ Number of Units Requested: ________________
Date(s) of Service: ______________________________________________Prior Authorization Request?
Yes
No
*Please explain the reason for requesting a hearing (the relief or action sought):_________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CONTINUED BENEFITS: Some types of assistance can be continued pending a hearing if hearing request is made within 10
days of the date of the notice with which you disagree. If the hearing decision supports the Department’s action and you are not
successful in any further appeal of that decision, you may have an overpayment if you received continued assistance. You will have to
pay back any overpayment.
Do you want your benefits continued?
I want my benefits continued.
I do not want my benefits continued.
You may represent yourself, have another person represent you, or retain an attorney to represent you. If you will be
represented by an attorney, the attorney must file a Notice of Appearance at least ten (10) days before any scheduled
hearing or prehearing. *Will you have attorney representation?
Yes
No
Name of Representative/Attorney: ____________________________________________________________________
Address: _______________________________________ Telephone Number: __________________________________
PLEASE ENCLOSE A COPY OF THE DENIAL NOTICE that caused you to request this hearing, and medical
records that support your position. Lack of appropriate and complete medical records will delay your hearing.
____________________________________________________________________
__________________________
Signature of person requesting hearing
Date
Name and address of additional person(s) you would like to be notified of your hearing:
__________________________________________
_____________________________________________
__________________________________________
_____________________________________________
:
SEND REQUEST TO
Via U.S. Post Office
Via UPS or FedEx
Director’s Office/Administrative Hearings
Director’s Office/Administrative Hearings
Division of Medicaid and Health Financing
Division of Medicaid and Health Financing
PO Box 143105
288 North 1460 West
Salt Lake City, UT 84114-3105
Salt Lake City, UT 84116-3231
Telephone: 801-538-6576 ~ Fax: 801-536-0143 ~ Email: administrativehearings@utah.gov
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