| Fair Hearing Request Form |
Office of Administrative Hearings
P.O. BOX 1930
Albany, NY 12201-1930
Fax:(518)
473-6735 |
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| Note: For security purposes, you have 15 minutes to complete this form, otherwise your request will not be received and you will need to start over. |
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Indicates Required Information. Correct and complete information will permit us to promptly process your request. |
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| Case Information |
| (If fair hearing is for someone other than the case name, describe who it is for in the comments box below.) |
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| Last name is required, and contains at least 2 letters and at most 36 letters |
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| First name is required, and contains at least 2 letters and at most 36 letters |
| Middle initial has to be one letter |
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| Street address is required, contains only 75 letters or numbers. |
| Suite/Floor/Apt# has to be letters or numbers, and cannot exceed 20 characters |
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| City is required, has at most 40 letters only |
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| State is required, has 2 letters only |
| Zip Code has at most 9 numbers |
| Invalid email format or it exceeds 75 characters |
| Phone number cannot exceed 10 numbers |
| Invalid date or exceed 10 characters |
| SSN must be 9 numbers, no dashes |
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| Enter numbers or letters, and cannot exceed 25 characters |
| Invalid Client ID Number or exceed maximum characters |
| Enter numbers only and cannot exceed 3 characters |
| Enter numbers only and cannot exceed 3 characters |
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| County or Center is required, and has no more than 20 letters or numbers. |
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| Language name is required and contains at most 15 letters. |
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| (If yes, please explain the client’s reason for being homebound in the Comments box below, and mail medical documentation to the above address. Do not delay submitting this fair hearing request form to obtain medical documentation.) |
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| RESTRICTIONS |
| Mark the days or times you or your representative cannot participate in a hearing and explain in the comment box below. We will not restrict the scheduling of the hearing unless an explaination is provided. |
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| Representative/Requestor Information |
| (If there is a representative or you are NOT the person listed above.) |
| Enter letters only and cannot exceed 75 characters |
| Enter letters only and cannot exceed 75 characters |
| Enter letters or numbers only, and cannot exceed 75 characters |
| Suite/Floor/Apt# has to be letters or numbers, and cannot exceed 20 characters |
| Enter letters only and cannot exceed 50 characters |
| Enter letters only and cannot exceed 2 characters |
| Zip Code has at most 9 numbers |
| Extension (limit 5 numbers)
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Phone has at most 10 numbers and extension has at most 5 numbers |
| Invalid email format or it exceeds 75 characters |
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| Enter comments to clarify information on this page including the reason for being homebound, additional mailing addresses, phone numbers and extensions, reason for restrictions, need to expedite a Medicaid hearing, etc. Later, you will have an opportunity to describe the reason you are asking for a fair hearing. |
Number of characters remaining for your description
: 500
Comments contain at most 500 characters, only letters, numbers, and regular punctuation marks. Multiple dashes or apostrophes are not allowed |
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| Enter the name of person filling out this form |
| Enter letters only and cannot exceed 50 characters |
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You must choose "My request is about a notice" or "My request is not about a notice" in order to continue. |
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You may add more issues later. |
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