Fair Hearing Request Form 1-01. Fair Hearing Request Form 1-01 - disabilityrightsca 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the person for whom the hearing is requested (the claimant) along with their date of birth.
3. Indicate whether the claimant is a Medicaid Home and Community Based Services Waiver participant by checking 'Yes' or 'No'.
4. Fill in the address and daytime telephone number of the claimant.
5. Specify the name of the regional center or state developmental center involved.
6. If you wish to resolve matters before a fair hearing, check any applicable options for an informal meeting or mediation.
7. Clearly describe your reasons for requesting a fair hearing and what is needed to resolve your complaint.
8. If you are not the claimant, provide your name, relationship to the claimant, and contact information.
9. Sign and date the request form, ensuring all required fields are completed accurately.
10. If necessary, indicate if interpreter services are required and specify the language needed.

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