Free 47845.FH11 - Indiana

REQUEST FOR ADMINISTRATIVE HEARING
State Form 47845 (R3 / 6-06) / OGC 0026

**IS THIS AN APPEAL OR A REQUEST FOR AGENCY REVIEW?** **IF THIS IS AN AGENCY REVIEW PLEASE CHECK APPROPRIATE BOX BELOW**
Name of case Address (number and street, city, state, and ZIP code) Name of county ICES number RID number

Date entered into HERQ system (month, day, year) T elephone number Prior authorization appeal (PA number, Social Security number, RID number)

(

)

Program TANF MEDICAID FOOD STAMPS CHILD CARE OTHER: (specify) Action DENIAL DISCONTINUANCE REDUCTION OTHER: Issue ASSISTANCE AMOUNT INCOME RESOURCES MEDICAL ELIGIBILITY PRIOR AUTHORIZATION FOR MEDICAL SERVICES Effective date of action (month, day, year) OTHER: Reason for appeal Mailing date of notice (month, day, year)

MEDICAL

AGENCY REVIEW

Signature of applicant / recipient; guardian; or authorized representative

Date received by local office (month, day, year - mandatory)

INSTRUCTIONS: 1.

ATTACH A COPY OF THE IMPORTANT NOTICE ABOUT YOUR BENEFITS, OR ANY OTHER NOTICE THAT SHOWS THE ACTION UNDER APPEAL.
All requests MUST be submitted on a 8 1/2" x 11" piece of paper. Forward to: MS 04 Hearings and Appeals Section 402 W. Washington St., E-034 Indianapolis, IN 46204

2. 3.

Food Stamp appeals may be entered into HERQ without a signed appeal request for Food Stamps appeals only. However, the information does need to be provided at the hearing. All other request must be in writing over the appellants signature.

** APPEALS MUST BE FAXED DAILY TO HEARINGS AND APPEALS AT (317) 232-4412 **
KEEP COPY FOR YOUR RECORDS