DODD Medicaid                                                                                                                                                                   

ODJFS Form #

 Title

Purpose

04002

State Hearing Scheduling Notice

Bureau of State Hearings Provides Medicaid state hearing    scheduling information (location/date/time) to consumer and agency.  See Also:   Explanation of State Hearing  procedures                     

04065  

Prior Notice of Right to State Hearing 

Agency notifies consumer of proposed change in benefits
and provides information about how to request Medicaid state hearing

04067

Appeal Summary 

Agency provides information to Bureau of State Hearings and consumer explaining its proposed action if Medicaid state hearing is requested

04068

State Hearing Compliance 

Agency demonstrates compliance with a Medicaid state hearing decision by filing this form with the Bureau of State Hearings

04069

State Hearing Request 

Consumer requests Medicaid state hearing by sending this form to Bureau   of State Hearings.   See Also: How to Request Medicaid State Hearing

07334

Notice of Denial of Application for Assistance

Agency notifies consumer of denial of application for benefits and provides information about how to request a Medicaid state hearing