Request for Fair Hearing

You can ask for a fair hearing (an appeal) if:

• You have been denied Medicaid
• Your Medicaid benefits have been cut
• Your Medicaid benefits have changed

If you want a fair hearing, call your county Department of Family and Children's Services today.  Then fill out this form.   Bring it or mail it to your county Department of Family and Children Services.

Today's Date: __________________________

Name of person who needs a fair hearing:____________________________________________

Signature: ____________________________

Telephone number where you can be reached: ____________________

Address: __________________________________________________

__________________________________________________________

Use this space to tell why you want a fair hearing.___________________________________________________________

___________________________________________________________

 Check one:

___ I do not want to continue receiving Medicaid while waiting for the hearing decision.

___ I want to continue receiving Medicaid while waiting for the hearing decision.

I understand that I could be required to repay Medicaid for benefits I receive while waiting for the decision if the hearing officer decides I was not entitled to Medicaid for that period.

NOTICE to DIVISION OF FAMILY AND CHILDREN SERVICES: 

Please mail or fax this fair hearing request (along with a copy of OSAH Form 1) to:

Department of Human Resources
Legal Services Section
2 Peachtree Street, NW - 29th Floor
Atlanta, Georgia 30303-3159

404-657-1123 (fax)

Georgia Legal Services Program
Document Last Revised: June 2004
Revised By: Linda Lowe and Vicky Kimbrell