Request for Hearing for Medicaid Enrollees, Pace Enrollees or Waiver Applicants
Michigan Office of Administrative Hearings and Rules
Michigan Department of Health and Human Services PO Box 30763, Lansing, MI 48909
Telephone Number: 800-648-3397	Fax: 517-763-0146
SECTION 1: To be completed by the PERSON REQUESTING A HEARING
Client Name	Client Telephone No.	Client Social Security No.
Client Address (No. and Street, Apt. No.)	Medicaid ID No.
City	State	Zip Code	Client or Legal Guardian Signature	Date
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 No.
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?
No	Yes (If yes, please explain here.)
Will you need an interpreter?
No	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?
No	Yes (If Yes, have the representative complete and sign Section 3.)
SECTION 3: AUTHORIZED HEARING REPRESENTATIVE INFORMATION
Name of Representative (please print)	Representative Telephone No.	Relationship to Enrollee
Address (No. and Street, Apt. No.)	City	State	Zip Code
Representative Signature	Date Signed
SECTION 4: AGENCY involved in the action being disputed by the client
Name of Agency	Agency Contact Person Name
Agency Address (No. and Street, Apt. No.)	Agency Telephone Number
City	State	Zip Code	State Program or Service being provided to this client

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 Office of Administrative Hearings and Rules for the Department of Health and Human Services or www.michigan.gov/LARA >> Bureau List >> Michigan Office of Administrative Hearings and Rules >> Benefit Services Hearings. 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-MOAHR, 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. 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 page 1 to: MICHIGAN OFFICE OF ADMINISTRATIVE HEARINGS AND RULES 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 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 or conservator must be included with this request.
Completion: Is Voluntary.

Michigan Department of Health and Human Services (MDHHS) Please note if needed, free language assistance services are available. Call 877-833-0870 (TTY users call TY: 711).
Spanish	ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 877-833-0870 (TTY 711).
Arabic	ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 877-833-0870 (رقم هاتف الصم والبكم:-TTY 711).
Chinese	注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 877-833-0870 (TTY 711）
Syriac (Assyrian)	ܙܘܼܗܵܪܵܐ: ܐܸܢ ܐܲܚܬܘܿܢ ܟܹܐ ܗܲܡܙܸܡܝܼܬܘܿܢ ܠܸܫܵܢܵܐ ܐܵܬܘܿܪܵܝܵܐ، ܡܵܨܝܼܬܘܿܢ ܕܩܲܒܠܝܼܬܘܿܢ ܚܸܠܡܲܬܹܐ ܕܗܲܝܲܪܬܵܐ ܒܠܸܫܵܢܵܐ ܡܲܓܵܢܵܐܝܼܬ. ܩܪܘܿܢ ܥܲܠ ܡܸܢܝܵܢܵܐ 877-833-0870 (TTY 711)
Vietnamese	CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 877-833-0870 (TTY 711).
Albanian	KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 877-833-0870 (TTY 711).
Korean	주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 877-833-0870 (TTY 711)번으로 전화해 주십시오.
Bengali	লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে। ফোন করুন ১-877-833-0870 (TTY 711)
Polish	UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 877-833-0870 (TTY 711).
German	ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer 877-833-0870 (TTY 711).
Italian	ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 877-833-0870 (TTY 711).
Japanese	注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。877-833-0870（TTY 711）まで、お電話にてご連絡ください
Russian	ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 877-833-0870 (телетайп 711).
Serbo-Croatian	OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 877-833-0870 (TTY Telefon za osobe sa oštećenim govorom ili sluhom 711).
Tagalog	PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 877-833-0870 (TTY 711).

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. Further, MDHHS:

Provides free aids and services to people with disabilities to communicate with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats); and

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Section 1557 Coordinator. The contact information is found below.

If you believe that MDHHS has not provided the above services, or discriminated in another way, you can file a grievance with the Section 1557 Coordinator. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator is available to help you.

MDHHS Section 1557 Coordinator

Compliance Office, 4th Floor

P.O. Box 30195

Lansing, MI 48909

517-284-1018 (Main), TTY 711, 517-335-6146 (Fax)

You can also file a civil rights complaint with the responsible federal agency.

If your grievance or complaint is about your Medicaid application, benefits or services you can file a civil rights complaint with the U.S. Department of Health and Human Services at https://bit.ly/2pBS4YG, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at https://bit.ly/2IKsHMS.	If your grievance or complaint is about your application for or current food assistance benefits, you can file a discrimination complaint with the U.S. Department of Agriculture (USDA) Program by: Completing a Complaint Form, (AD-3027) found online at: https://bit.ly/2g9zzpU or at any USDA office, or write a letter addressed to USDA at the address below. In your letter, provide all the information requested in the form. To request a copy of the complaint form, call 866-632-9992. Send your completed form or letter to USDA by mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 Fax: 202-690-7442; or Email: program.intake@usda.gov

MDHHS is an equal opportunity provider.