RFP 240000001827 - Attachment H - Hearing Request.doc

REQUEST FOR HEARING FOR MEDICAID ENROLLEES,

PACE ENROLLEES OR WAIVER APPLICANTS

Michigan Administrative Hearing System

For the Michigan Department of Health and Human Services

PO Box 30763

Lansing, MI 48909

SECTION 1 – To be completed by the PERSON REQUESTING A HEARING

What agency took the action or made the decision that you are appealing?

Make sure to attach a copy of the letter from the agency that told the client about their decision.

Client MDHHS Case Number

I WANT TO REQUEST A HEARING: The following are my reasons for requesting a hearing. Use Additional Sheets if Needed.

Do you have a physical disability or other condition requiring special arrangements for you to attend or participate in a hearing?

FORMCHECKBOX

No

FORMCHECKBOX

Yes (If yes, please explain here.)

Will you need an interpreter?

FORMCHECKBOX

No

FORMCHECKBOX

Yes (If yes, language needed:)

SECTION 2 – Have you chosen someone to represent you at the hearing?

Has someone agreed to represent you at this hearing?

FORMCHECKBOX

NO

FORMCHECKBOX

Yes (If Yes, have the representative complete and sign Section 3.)

SECTION 3 – Authorized Hearing Representative Information

SECTION 4 – To be completed by the AGENCY involved in the action being disputed by the client

This form is also available online at: www.michigan.gov/mdhhs >> Assistance Programs >> Medicaid >> Program Resources >> Michigan Administrative Hearing System for the Department of Health and Human Services or www.michigan.gov/LARA >> MI Administrative Hearing System >> Benefit Services

REQUEST FOR HEARING FOR MEDICAID ENROLLEES,

PACE ENROLLEES OR WAIVER APPLICANTS

Instructions

A hearing is an impartial review of a decision made by the Michigan Department of Health and Human Services or one of its contract agencies that a client believes is wrong.

This form is to ask for a hearing if you are a Medicaid enrollee, or a PACE enrollee, or a Medicaid waiver applicant when the action has been taken by MDHHS or one of its contract agencies. You can also send in your signed hearing request in writing on any paper. This form is also available online at: www.michigan.gov/mdhhs >> Assistance Programs >> Medicaid >> Program Resources >> Michigan Administrative Hearing System for the Department of Health and Human Services or www.michigan.gov/LARA >> MI Administrative Hearing System >> Benefit Services.

Do not use this form to appeal an action

· Taken by a Medicaid, Healthy Michigan Plan or MI Health Link health plan, Community Mental Health Services Program / Prepaid Inpatient Hospital Plan (CMHSP/PIHP), Healthy Kids Dental health plan, or MI Choice Waiver Agency. You must go through their internal appeals process first before you ask for a MDHHS-5617-MAHS, Request for State Fair Hearing form. This form is also available online at the links above.

· Related to program eligibility, cash assistance, food assistance, or other assistance programs. You must use the DHS-18, Request for Hearing form available online at www.michigan.gov/mdhhs >> Doing Business with MDHHS >> Forms and Applications >> Other, or go to www.michigan.gov/documents/FIA-Pub18_14356_7.pdf to download the form.

GENERAL INSTRUCTIONS

· Read ALL instructions before completing the attached form.

· Complete Section 1 using the name of the client (even if the client has a guardian or is a minor).

· Complete Sections 2 & 3 only if the client wants someone to represent them at the hearing.

· Complete Section 4 if the agency who took the action you are appealing did not fill this out.

· Attach a copy of the notice or letter from the Agency that told the client about the change that is being appealed.

· Please make a copy for your records.

· Questions can be answered by calling toll free: 800-648-3397.

· After the form is completed, mail or fax to:

MICHIGAN ADMINISTRATIVE HEARING SYSTEM

FOR THE MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

PO BOX 30763

LANSING MI 48909

Fax 517-763-0146

· The client may choose to have another person represent them at a hearing.

· This person can be anyone the client chooses but he/she must be at least 18 years of age.

· The client must give this person written permission to represent them.

· The client may give written permission by checking yes in Section 2 and having the person who is representing them complete Section 3. The client must still complete and sign Section 1.

· The client's guardian or conservator may represent them. A copy of the court order naming the guardian must be included with this request.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

If you need help with reading, writing, or hearing, you are invited to make your needs known to the Michigan Department of Health and Human Services.

If you do not understand this, call the Michigan Department of Health and Human Services at 877-833-0870.

Si no entiende esta información comuníquese al Michigan Department of Health and Human Services al 877-833-0870.

877-833-0870

Completion: Is Voluntary

DCH-0092-MAHS (Rev. 7-18) Previous edition obsolete.