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 DDS Hearings Forms  Dgs Ca Gov  State of California 2007-2023

DDS Hearings Forms Dgs Ca Gov State of California 2007-2023

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The director s designee. State of California Health and Human Services Agency Department of Developmental Services Page 1 of 2 Reset Form FAIR HEARING REQUEST Print DS 1805 Rev. 1/2007 Name of Person for Whom Hearing is Requested Claimant Date of Birth Address Medicaid Home and Community Based Services Waiver Participant Check one Yes No Daytime Telephone Number Name of Regional Center or State Developmental Center A State level fair hearing will be scheduled. In an effort to resolve this...
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