Effective Date: 
4/2017

Documents

 

Instructions

Updated: 4/2017

 

Use

Form 1505 is completed by an applicant or consumer to initiate the DRS and DBS process for a due process hearing or mediation.

 

Copies and Distribution

N/A

 

Retention

The original form is maintained in the HHS Legal Hearings file for three years following the end of the fiscal year, in accordance with the HHS Retention Schedule.

 

Detailed Instructions

Hearing Request Information—Choose one of the determinations or concerns listed.
Authorization—Applicant or consumer must sign. If signing with an “X”, signatures of two witnesses are required.

 

Acronyms and Definitions

N/A

 

Special Instructions

N/A

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