Form Doh Cdpap 01 is a form that you will use to request an exemption from the requirements of the Child and Dependent Care Assistance Program. This program provides financial assistance to families who are caring for a child or dependent adult. If you believe that you meet the qualifications for an exemption, you can complete this form and submit it to your state's social services agency. By doing so, you may be able to receive benefits from the Child and Dependent Care Assistance Program without compliance with its requirements. Note that each state has their own set of requirements for eligibility, so be sure to review these before submitting your application. Failure to do so could result in rejection of your exemption request. Good luck!
| Question | Answer |
|---|---|
| Form Name | Form Doh Cdpap 01 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | CIN, 2011, nys doh notice of decision for cdpap doh cdpap 02, nys doh notice of decision for cdpap doh cdpap 01 |
MA Only |
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(9/2011) |
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NOTICE OF DECISION OF INITIAL AUTHORIZATION/
REAUTHORIZATION/OR DENIAL CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM
SERVICES
NOTICE DATE: |
EFFECTIVE DATE: |
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CASE NUMBER |
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CIN NUMBER |
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CASE NAME (And C/O Name if Present) AND ADDRESS
NAME AND ADDRESS OF AGENCY/CENTER OR DISTRICT OFFICE
GENERAL TELEPHONE NO. FOR
QUESTIONS OR HELP
OR Agency Conference
Fair Hearing Information
and Assistance
Record Access
Legal Assistance Information
OFFICE NO.
UNIT NO.
WORKER NO. |
UNIT OR WORKER NAME |
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TELEPHONE NO.
This is to inform you of the following action taken on your request for Consumer Directed Personal Assistance Program services effective ______________________.
(Please read carefully)
INITIALLY AUTHORIZED
Consumer Directed Personal Assistance Program services have been initially authorized for ____________ hours per week. Your authorization period is from ____________________________ to _______________________________________.
REAUTHORIZED
Consumer Directed Personal Assistance Program services have been reauthorized for _________________ hours per week.
Your authorization period is from ________________________________ to ___________________________________.
DENIED
We intend to take this action because:
The law and/or regulation(s) which allow us to do this are 18 NYCRR 505.14.
SIGNATURE OF WORKER
X
REGULATIONS REQUIRE THAT YOU IMMEDIATELY NOTIFY THIS DEPARTMENT
OF ANY CHANGES IN NEEDS, INCOME, RESOURCES, LIVING ARRANGEMENTS OR ADDRESS
YOU HAVE THE RIGHT TO APPEAL THIS DECISION
BE SURE TO READ THE BACK OF THIS NOTICE ON HOW TO APPEAL THIS DECISION
RIGHT TO A CONFERENCE: You may have a conference to review these actions. If you want a conference, you should ask for one as soon as possible. At the conference, if we discover that we made the wrong decision or if, because of information you provide, we determine to change our decision, we will take corrective action and give you a new notice. You may ask for a conference by calling us at the number on the first page of this notice or by sending a written request to us at the address listed at the top of the front page of this notice. This number is used only for asking for a conference. It is not the way you request a fair hearing. If you ask for a conference you are still entitled to a fair hearing. Read below for fair hearing information.
RIGHT TO A FAIR HEARING: If you believe that the above action is wrong, you may request a State fair hearing by:
1)Telephone: You may call the state wide toll free number:
2)Fax: Send a copy of this notice to fax no. (518)
3)
http://www.otda.state.ny.us/oah/forms.asp. OR
4)Write: Send a copy of this notice completed, to the Fair Hearing Section, New York State Office of Temporary and Disability Assistance, P.O. Box 1930, Albany, New York 12201. Please keep a copy for yourself.
5)New York City participants ONLY: You may also
I want a fair hearing. The Agency’s action is wrong because:_______________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Print Name: __________________________________________________________ Case Number__________________
Address: ___________________________________________________________Telephone: ________________
Signature of Client: ____________________________________________________ Date: _______________________
YOU HAVE 60 DAYS FROM THE DATE OF THIS NOTICE TO REQUEST A FAIR HEARING
If you request a fair hearing, the State will send you a notice informing you of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, a friend or other person, or to represent yourself. At the hearing you, your attorney or other representative will have the opportunity to present written and oral evidence to demonstrate why the action should not be taken, as well as an opportunity to question any persons who appear at the hearing. Also, you have a right to bring witnesses to speak in your favor. You should bring to the hearing any documents such as this notice, pay stubs, receipts, medical bills, heating bills, medical verification, letters, etc. that may be helpful in presenting your case.
LEGAL ASSISTANCE: If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid Society or other legal advocate group. You may locate the nearest Legal Aid Society or advocate group by checking your Yellow Pages under “Lawyers” or by calling the number indicated on the front of this notice.
ACCESS TO YOUR FILE AND COPIES OF DOCUMENTS: To help you get ready for the hearing, you have a right to look at your case file. If you call or write to us, we will provide you with free copies of the documents from your file which we will give to the hearing officer at the fair hearing. Also, if you call or write to us, we will provide you with free copies of other documents from your file which you think you may need to prepare for your fair hearing. To ask for documents or to find out how to look at your file, call us at the Record Access telephone number listed at the top of the front of this notice or write us at the address printed at the top of the front of this notice.
If you want copies of documents from your case file, you should ask for them ahead of time. They will be provided to you within a reasonable time before the date of the hearing. Documents will be mailed to you only if you specifically ask that they be mailed.
INFORMATION: If you want more information about your case, how to ask for a fair hearing, how to see your file, or how to get additional copies of documents, call us at the telephone numbers listed at the top of the front of this notice or write to us at the address printed at the top of the front of this notice.
ATTENTION: Children under 19 years of age who are not eligible for Medicaid or other health insurance may be eligible for the Child Health Plus Insurance. The plan provides health care insurance for children. Call