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
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.
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