Administrative Hearing Request
Department of Human Services (DHS) or Oregon Health Authority (OHA) completes this part
Date RECEIVED by DHS or OHA:
(can be oral for SNAP and Medical programs)
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Is claimant English speaking? If no, claimant understands:
Alternate format? |
Yes |
Braille |
Audio tape |
If “yes,” please specify;
Diskette |
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Oral presentation |
Claimant or claimant’s representative completes this part
If you want a hearing for cash, child care, or medical services (specific medical procedure or medicine), you or your representative must fill out this form. You can also use this form to ask for a medical program or food benefit hearing, but are not required to. A DHS or OHA employee can help you complete this form.
Claimant’s name: |
Telephone number: |
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Email address (optional) |
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I am asking for a hearing because I do not agree with the decision to
Deny |
Charge me with an overpayment |
Other: |
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I did |
receive a written notice to deny my application or to reduce or close |
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Date of the notice: |
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I did not |
my benefits. |
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Hearing requested for: |
SNAP (Food benefits) |
Child Care |
TANF (Cash) |
Other: |
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Long-Term Care |
Domestic Violence |
Medical Program |
Medical Service (procedure or medicine) |
Briefly explain why you disagree. |
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Please read “part 3” on the back of this form for information about expedited hearings.
Check this box if you meet the requirements for an expedited hearing.
Before you answer this question, please read “part 2” on the back of this form.
Do you want your benefits to stay the same (not be reduced or stopped) while you wait for the hearing? Yes No (NOTE: Your benefits may change if something else happens that affects the amount.)
The administrative law judge may conduct the hearing by phone.
In a telephone hearing, the administrative law judge participates by phone. The client may be at the branch or another place. I understand I will be asked to have an informal conference with an agency representative.
Claimant’s signature (or claimant’s representative): |
Claimant’s Social Security or case number: |
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The Department of Human Services (DHS) and the Oregon Health Authority (OHA) are authorized to request your Social Security Number (SSN) under 42 USC 1320b-7(a) and (b), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920, 42 CFR 457.340(b), and OAR 461-120-0210. Your SSN will be used to locate your file and records. Providing an SSN is voluntary.
DHS|OHA completes this part
DHS representative for this matter: |
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Issue code: |
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Issue resolved at branch level? Yes |
No |
Ordered issued: |
Client withdraw |
Agency withdraw |
Dismissal |
MSC 0443 (1/14), CAN USE PRIOR VERSION
MSC 0447 (01/14) Can use prior version
Your Hearing Rights
What you can do when you do not agree with this decision:
•You have the right to challenge this decision by requesting a hearing. Hearings are held by the Office of Administrative Hearings, which is independent from the Department of Human Services (DHS) or Oregon Health Authority (OHA).
If you want a hearing, you must request it on time.
•You can also talk with a manager. You can call a local office phone number listed at http://www.oregon.gov/dhs/ localoffices/localoffices.pdf. Your deadline date to request a hearing (part 1 below) does not change even if you are in contact with a manager or are trying to reach one. If you still need further assistance, you may contact the Governor’s Advocacy Office at 1-800-442-5238.
Part 1 — Ask for a hearing.
What must I do to get a hearing? For food benefits and medical eligibility, you can ask for a hearing on form MSC 0443, by phone, in writing, or by asking a DHS employee in person. For other benefits, you must fill out an Administrative Hearing Request form (MSC 0443) and return it to a DHS or OHA office. You can get this form at a DHS or OHA office or on the web at https://apps.state.or.us/Forms/Served/me0443.pdf. Your local office can help you with a hearing request. You may request a hearing at any time if you disagree with the current amount of your food benefits. You have 90 days to request a hearing for food benefits, medical eligibility, and for TANF reductions for not cooperating with your case plan. In other situations, DHS must receive your request within 45 days from the date on the notice.
Note to military personnel: Active duty service members have a right to stay (delay) these proceedings under the federal Servicemembers Civil Relief Act (SCRA). For more information, you may contact the Oregon State Bar (1-800-452-8260), the Oregon Military Department (1-800-452-7500) or the nearest legal assistance office, legalassistance.law.af.mil.
Who can help with my hearing? For food benefits and for medical programs, anyone may represent you. In all other programs, you must represent yourself or have a lawyer or a legal assistant (supervised by a Legal Aid attorney) represent you. You may call the Public Benefits Hotline (a program of Legal Aid Services of Oregon and the Oregon Law Center) at
1-800-520-5292 for advice and possible representation.
What are my other hearing rights? At the hearing, you can tell why you do not agree with the decision. You can have people testify for you. The laws about your hearing rights and the hearing process are at OAR 137-003-0501 to 0700, 410- 120-1860, 410-141-0264, 461-025-0300 to 0375, ORS 183.411 to 183.470 and ORS 411.095.
What happens if there is no hearing? If you do not ask for a hearing on time, or if you withdraw the hearing request or miss your hearing, you may lose your right to a hearing. This notice will be the final DHS or OHA decision (called a “final order by default”). You will not get a separate final order by default. The case file, along with any materials you submitted in this matter, is the record. The record is used to support the DHS decision upon default. You may appeal the final order by default by filing a petition in the Oregon Court of Appeals (ORS 183.482). If you do not ask for a hearing, this appeal must be filed within 60 days of the date this notice becomes a final order, by default. If you withdraw a hearing request or miss your hearing, the appeal deadline is set out in the dismissal order.
Part 2 — How can I keep getting benefits until my hearing?
•You can ask for your benefits to stay the same until the hearing decision (“continuing benefits”). For food and medical benefits, use form MSC 0443, phone, write or ask a DHS employee in person. In other programs, you must ask on the Administrative Hearing Request form (MSC 0443).
•You must ask your branch for continuing benefits by either the “effective date” on the notice, 10 days after the date of the notice, or (for medical only) 10 days after receipt of the notice. You must ask by whichever date is later.
•If you keep getting benefits but lose the hearing, you must pay back the benefits you should not have received.
•If you don’t keep getting benefits and win the hearing, DHS or OHA will give you the benefits you should have received.
Part 3 — Can I have an expedited hearing?
You may have the right to an “expedited hearing” for any of the following types of benefits or situations:
•Expedited or emergency food benefits
•JOBS and Pre-TANF payments
•Temporary Assistance for Domestic Violence Survivors (TA-DVS) eligibility and payments
•In a medical case, you have an immediate need for health services and standard timeline for the appeal process could jeopardize your life or health or ability to attain, maintain, or regain maximum function
•DHS or OHA denied your request to keep getting benefits until your hearing.
DHS and OHA do not discriminate against anyone. This means that DHS|OHA will help all who qualify and will not treat anyone differently because of age, race, color, national origin, gender, religion, political beliefs, disability or sexual orientation. You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons.
