FORM TO FILE A STATE HEARING FROM A MANAGED CARE DENIAL
You can ask for a State Hearing by calling: 1-800-743-8525. TDD users, call
1-800-952-8349. You can also request a hearing in the following ways:
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You can request a hearing ONLINE at WWW.DSS.CA.GOV
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You can fill out this form and FAX it to State Hearings at 916-651-2789
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Note: If you send it by email, please understand there is a risk that someone other than the
State Hearings Division could intercept your email. Please consider using a more secure
method of sending your request.)
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You can also MAIL this State Hearing Request to:
California Department of Social Services
State Hearings Division
P.O. Box 944243, MS 9-17-37
Sacramento, CA 94244-2430
For free help filling out this form, call the legal help phone number listed on the
attached ‘Your Rights’ Notice
I do not agree with the decision about my health care. State the treatment,
drug, equipment, or service that the doctor requested. I disagree because:
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If you need more space, use another piece of paper and attach it to this one.)
PLEASE PROVIDE THIS INFORMATION ABOUT THE BENEFICIARY
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This is the person who was denied medical benefits)
NAME:_______________________________________________________________________
DATE OF BIRTH: _____________________________________________________________
ADDRESS (Where you can get mail): ___________________________________________
TELEPHONE NUMBER:_________________________________________________________
Do we have your permission to communicate with you by email? [
] YES [
] NO
If Yes, what is your EMAIL ADDRESS:
Please provide your Medi-Cal BIC Card Number and /or Social Security Number if you
have one _______________________________________________________________________
Do you have Straight Medi-Cal (Fee for Service) or Managed Care? ______________________
If Managed Care, what is the name of your HEALTH PLAN: ___________________________
Revised 05.09.17