FAIR HEARING REQUEST FORM
Office of Administrative Hearings
P.O. BOX 1930
Albany, NY 12201-1930
Fax:(518) 473-6735
 
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.
 
  Indicates Required Information. Correct and complete information will permit us to promptly process your request.
 
Case Information
(If fair hearing is for someone other than the case name, describe who it is for in the comments box below.)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(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.)
 
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.
 
 
Representative/Requestor Information
(If there is a representative or you are NOT the person listed above.)
 
 
 
 
 
 
 
Extension:(limit 5 numbers)  
 
 
Enter comments to clarify information on this page including the reason for being homebound, additional mailing addresses,
phone numbers and extensions, reason for restrictions, etc.   Later, you will have an opportunity to describe the reason you
are asking for a fair hearing.

You have 500 characters remaining for your description...
 
 
Enter the name of person filling out this form
 
 
  You must choose "My request is about a notice" or "My request is not about a notice" in order to continue.
 
    
    You may add more issues later.