Dhs 18 PDF Details

As parents, we all want what is best for our children. We work hard to provide them with a safe and happy home, good food, and opportunities to succeed in life. One of the most important things we can do for our children is to make sure they have access to healthcare. The Department of Health and Human Services has created a program called Dhs 18 that provides free or low-cost health insurance for children. Here are some things you need to know about Dhs 18. The Dhhs 18 program was created in 2014 as a way to provide affordable healthcare coverage for uninsured children living in California.

If you need to first learn how much time you will need to fill out the dhs 18 and what number of pages it's got, here is some detailed data that may be of use.

QuestionAnswer
Form NameDhs 18
Form Length2 pages
Fillable?Yes
Fillable fields71
Avg. time to fill out14 min 46 sec
Other namesmdhhs specialist request online, hearing request any, how to michigan form dhs 18, request michigan assistance

Form Preview Example

Case Name:

 

Case Number:

 

Date:

 

MDHHS Office:

 

Specialist / ID:

/

Phone:

 

Fax:

 

Individual ID:

 

ENTER ADDRESSEE NAME ENTER ADDRESSEE CARE OF

ENTER ADDRESSEE PO BOX OR STREET ENTER ADDRESSEE CITY/STATE/ZIP

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.

“USDA is an equal opportunity provider and employer.”

AUTHORITY: MCL 400.9, MSA 16,409

RESPONSE: Voluntary.

PENALTY: None

REQUEST FOR HEARING

INSTRUCTIONS: Complete items 1 through 14 on following page. Please type or print. DELIVER OR MAIL completed form to your local

MDHHS office, Attn: Hearing Coordinator. A date-stamped copy will be returned to you by the local office.

Date Received in MDHHS

Program(s) in Dispute

If you do not agree with any decision made by MDHHS to deny, reduce or terminate benefits, you have the right to request a hearing. In most cases, if you receive a notice reducing or canceling your benefits and you request a hearing no more than 11 days after the date the action will take place, your benefits will continue until the hearing is decided. Although, if the MDHHS decision to deny, reduce or terminate your benefits is upheld, you will be required to repay any additional benefits received because the action was postponed.

Someone else may represent you at the hearing, such as a friend, relative, or lawyer. Hearings will be conducted by telephone unless an in- person hearing is requested.

To Ask for a Hearing:

A request for an administrative hearing must be made in writing and signed by you or someone authorized to act on your behalf. For convenience, MDHHS provides a hearing request form that you should bring or mail to your MDHHS office (no faxes or photocopies). For FAP (food assistance) only, you can request a hearing verbally, in person or by telephone. Except for FAP, the hearing request must be signed by you or by your parent, attorney, court appointed guardian or conservator, or by someone else you formally designate as your Authorized Hearing Representative. For Medicaid only, a spouse may sign a written request for a hearing without first being designated an Authorized Hearing Representative.

Appointment of an Authorized Hearing Representative:

The appointment of an authorized hearing representative must be made in writing and signed by you before that person can make a hearing request, or take any other action on your behalf. The Hearing request will be denied if it is signed by a person not authorized by law, court order, or a signed statement from you.

Your Hearing Request will be Denied if:

We receive your request more than 90 days after we mail the notice to deny, terminate, or reduce your benefits.

The person who signed the hearing request cannot show a court order or a signed statement from you, and is not your lawyer, spouse or parent.

Persons with Disabilities or Needing Special Arrangements:

Special arrangements at the hearing can be made to accommodate a physical disability or other barrier to participation that you or someone participating with you needs. If an interpreter is required, please indicate the language skills needed. Tell your MDHHS specialist if you need help.

DHS-18 (Rev. 6-15) Previous edition obsolete. MS Word

1

Case Name

Case Number

Specialist

1.Please check only the box(es) of the benefit program(s) you are asking to have heard before an administrative law judge and the action taken which you are challenging.

FIP (Cash)

MA (Medical)

CDC (Child Care)

Other

Denied

Denied

Denied

Denied

Closed

Closed

Closed

Closed

Amount

Amount

Amount

Amount

FAP (Food)

SER (Emergency Relief)

SDA (Cash)

Denied

Denied

Denied

Closed

Closed

Closed

Amount

Amount

Amount

2. I request a hearing before an Administrative Law Judge regarding the decision of the

 

 

County

 

Michigan Department of Health and Human Services. I believe the department’s decision is wrong because:

Name of County

 

 

 

 

EXPLANATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.If necessary for participation at the hearing and upon request, arrangements can be made to accommodate a physical disability. If an interpreter is required, please indicate what language.

Please identify the disability or language barrier, and explain what arrangements are required:

If at the hearing, you are denied special help or an exception you need because of a disability and you think the denial was wrong, you may file a complaint of discrimination using the DHS-866 form. The DHS-866 provides the address for filing a complaint with the MDHHS Office of Human Resources.

By signing this form, I acknowledge that I have read and understand the following rights and obligations: Because I am asking for a hearing, the MDHHS may postpone the proposed action until I have had a hearing and a decision is issued by an Administrative Law Examiner. If MDHHS’ proposed action is upheld, I will be required to repay any additional benefits that I received because the proposed action was postponed. If I withdraw this hearing request, or if I do not go to the hearing when it is scheduled, I will be required to repay any additional benefits that I received because the proposed action was postponed.

I

DO

DO NOT want to continue receiving the amount of food assistance I now receive until after my hearing.

4.

Signature of Person Requesting Hearing (AH must receive an original

5.

Telephone Number

6. Date

 

signature. If this form is signed by an authorized hearing representative,

 

 

 

 

documentation of authorization must be attached.)

 

 

 

 

 

 

 

 

 

 

7.

Case Number:

 

 

 

 

 

 

8.

Street Address or Route Number

9.

City, State and Zip Code

 

 

 

 

 

 

THIS SECTION TO BE COMPLETED ONLY IF SOMEONE HAS AGREED TO REPRESENT YOU AT THE HEARING.

10.

Name of Authorized Hearing Representative

11.

Telephone Number

12. Title

 

 

 

 

 

13.

Street Address or Route Number

14.

City, State, and Zip Code

 

El Michigan Department of Health and Human Services (MDHHS) no discrimina contra ningún individuo o grupo a causa de su raza, religión, edad, origen nacional, color de piel, estatura, peso, estado matrimonial, información genética, sexo, orientación sexual, identidad de sexo o expresión, creencias políticas o incapacidad.

DHS-18 (Rev. 6-15) Previous edition obsolete. MS Word

2

How to Edit Dhs 18 Online for Free

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filling in hearing request any step 1

Enter the required details in the space ENTER ADDRESSEE NAME, ENTER ADDRESSEE CARE OF, ENTER ADDRESSEE PO BOX OR STREET, ENTER ADDRESSEE CITY/STATE/ZIP, The Michigan Department of Health, INSTRUCTIONS: Complete items 1, REQUEST FOR HEARING, Program(s) in Dispute, and Date Received in MDHHS If you do.

hearing request any ENTER ADDRESSEE NAME, ENTER ADDRESSEE CARE OF, ENTER ADDRESSEE PO BOX OR STREET, ENTER ADDRESSEE CITY/STATE/ZIP, The Michigan Department of Health, INSTRUCTIONS: Complete items 1, REQUEST FOR HEARING, Program(s) in Dispute, and Date Received in MDHHS If you do fields to fill out

Mention the crucial particulars in Case Name, Case Number, Specialist, are challenging, MA (Medical), CDC (Child Care), Other, Denied, Denied, Denied, Denied, Closed, Closed, Closed, Closed, Amount, FAP (Food), Denied, Closed, Amount, Amount, SER (Emergency Relief), Denied, Closed, Amount, Amount, SDA (Cash), Denied, Closed, Amount, Amount, I request a hearing before an, Name of County, and County field.

stage 3 to filling out hearing request any

As part of section If necessary for participation at, and Please identify the disability or, indicate the rights and obligations.

If necessary for participation at, and Please identify the disability or in hearing request any

Review the sections THIS SECTION TO BE COMPLETED ONLY, El Michigan Department of Health, and DHS-18 (Rev and thereafter fill them in.

step 5 to finishing hearing request any

Step 3: In case you are done, select the "Done" button to export the PDF file.

Step 4: Ensure you remain away from possible problems by having a minimum of 2 duplicates of the document.

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