Administrative Hearing Request
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Administrative Hearing Request
Department of Human Services (DHS) or Oregon Health Authority (OHA) completes this part
Date of notice:
Date Received by DHS or OHA:
Program no.:
Cost center/branch no.:
Case number:
Worker ID:
(Request can be verbal for SNAP)
/
/
/
/
Is claimant English speaking?
Yes
No Alternate format
Yes
No
If “yes,” please specify;
Braille
Audio tape
Large print
Diskette
Oral presentation
If no, claimant understands:
Claimant or claimant’s representative completes this part
If you want a hearing for cash, child care, or medical benefits, you or your representative must fill out this form. You
can also use this form to ask for a food benefit hearing, but you are not required to. An employee at your branch office
can help you complete this form.
Claimant’s name:
Telephone number:
Message number:
-
-
-
-
Address:
City:
State:
ZIP code:
Name of lawyer or representative:
Telephone number:
-
-
Address:
City:
State:
ZIP code:
I am asking for a hearing because I do not agree with the decision to
Close
Reduce my benefits
Deny
Charge me with an overpayment
Other:
I did
receive a written notice to deny my application or to reduce or close
Date of the notice:
my benefits.
/
/
I did not
Program(s) Involved:
Medical
TANF (Cash)
Child Care
SNAP (Food benefits)
Long-Term Care
Domestic Violence
Other:
Briefly explain why you disagree.
Please read “part 3” on the back of this form for information about expedited hearings.
Check this box if you meet the requirements for an expedited hearing.
Before you answer this question, please read “part 2” on the back of this form.
Do you want your benefits to stay the same (not be reduced or stopped) while you wait for the hearing?
Yes
No
(Note: Your benefits may change if something else happens that affects the amount.)
The administrative law judge may conduct the hearing by phone.
In a telephone hearing, the administrative law judge participates by phone. The client may be at the branch or another
place. I understand I will be asked to have an informal conference with an agency representative.
Claimant’s signature (or claimant’s representative):
Claimant’s Social Security or case
Date:
number:
The Department of Human Services (DHS) and the Oregon Health Authority (OHA) are authorized to request your Social Security Number
(SSN) under 42 USC 1320b-7(a) and (b), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920, 42 CFR 457.340(b), and OAR 461-120-0210.
Your SSN will be used to locate your file and records. Providing an SSN is voluntary.
DHS|OHA completes this part
DHS representative for this matter:
Date:
Issue code:
Telephone number:
-
-
-
-
Issue resolved at branch level?
Yes
No
Ordered issued:
Client withdraw
Agency withdraw
Dismissal
Distribution: White: Office of Administrative Hearings
Canary: Agency case file
Pink: Claimant
MSC 0443 (12/12), Can use prior version
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