Form DR107 "Request for Mediation and/Or Fair Hearing" - California

What Is Form DR107?

This is a legal form that was released by the California Department of Rehabilitation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2012;
  • The latest edition provided by the California Department of Rehabilitation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DR107 by clicking the link below or browse more documents and templates provided by the California Department of Rehabilitation.

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Download Form DR107 "Request for Mediation and/Or Fair Hearing" - California

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STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
REQUEST FOR MEDIATION AND/OR FAIR HEARING
DR 107 (Rev. 08/12)
Page 1 of 2
PRIVACY STATEMENT - The information requested on this form, including name and address, is necessary
for identification. Failure to provide the information requested may result in delays in services.
Consumer Name
SSN (last
4 digits)
DOR Counselor Name
XXX-XX-
Telephone Number
Check if TTY
E-mail Address
Residence Address
City
State
Zip Code
Mailing Address, If Different
City
State
Zip Code
Client Assistance Program (CAP)
If you need help filling out this form or want assistance in resolving a problem with the DOR, you may
speak to a local CAP advocate. Call toll free at 1-800-776-5746 (voice), 1-800-719-5798 (TTY), or
visit the CAP webpage
www.disabilityrightsca.org/about/cap.html
I am dissatisfied with a decision or action by the DOR and request one or both of the following:
Mediation
- I request that an impartial mediator assist me and the DOR in resolving our
different viewpoints regarding a DOR decision made or action taken within one year of this
request.
(Mediation will be held within 25 calendar days from receipt of your request, unless you
agree to a later date.)
Fair Hearing
- I request a hearing before an impartial hearing officer who will review a
decision made or action taken by the DOR.
(Hearing requests must be made within 30 calendar days of your receipt of an
Administrative Review Decision or within one year of the date of the decision or action
with which you disagree.)
Explain the DOR decision made (and date), or action taken (and date) with which you disagree:
Why do you disagree and how do you want the problem solved?
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
REQUEST FOR MEDIATION AND/OR FAIR HEARING
DR 107 (Rev. 08/12)
Page 1 of 2
PRIVACY STATEMENT - The information requested on this form, including name and address, is necessary
for identification. Failure to provide the information requested may result in delays in services.
Consumer Name
SSN (last
4 digits)
DOR Counselor Name
XXX-XX-
Telephone Number
Check if TTY
E-mail Address
Residence Address
City
State
Zip Code
Mailing Address, If Different
City
State
Zip Code
Client Assistance Program (CAP)
If you need help filling out this form or want assistance in resolving a problem with the DOR, you may
speak to a local CAP advocate. Call toll free at 1-800-776-5746 (voice), 1-800-719-5798 (TTY), or
visit the CAP webpage
www.disabilityrightsca.org/about/cap.html
I am dissatisfied with a decision or action by the DOR and request one or both of the following:
Mediation
- I request that an impartial mediator assist me and the DOR in resolving our
different viewpoints regarding a DOR decision made or action taken within one year of this
request.
(Mediation will be held within 25 calendar days from receipt of your request, unless you
agree to a later date.)
Fair Hearing
- I request a hearing before an impartial hearing officer who will review a
decision made or action taken by the DOR.
(Hearing requests must be made within 30 calendar days of your receipt of an
Administrative Review Decision or within one year of the date of the decision or action
with which you disagree.)
Explain the DOR decision made (and date), or action taken (and date) with which you disagree:
Why do you disagree and how do you want the problem solved?
STATE OF CALIFORNIA
DEPARTMENT OF REHABILITATION
REQUEST FOR MEDIATION AND/OR FAIR HEARING
DR 107 (Rev. 08/12)
Page 2 of 2
Consumer Name
Consumer' s Authorized Representative Name:
Client Assistance Program
Yes
No
Email Address
Residence Address
City
State Zip Code
Mailing Address, If Different
City
State Zip Code
To participate in mediation and/or fair hearing, I will need the following accommodations (such as
interpreters, assistive listening systems, or alternate formats):
By signing this form, I consent to the release of information on this form and the information
necessary to carry out the mediation and/or fair hearing to the mediator(s), impartial hearing
officer(s), mediation and/or hearing staff, and my representative.
Consumer Signature
Date Signed
For both Mediation and/or Fair Hearing requests:
Mail the signed request to:
OR fax the signed request to:
Mediation and Fair Hearing Office
(916) 558-5861
c/o Department of Rehabilitation
Attention - Mediation and Fair Hearing Office
Legal Affairs
P. O. Box 944222
OR email the signed request
Sacramento, CA 94244-2220
to:appealsinfo@dor.ca.gov
OR hand carry the signed request to:
For information about mediation services and/or
Mediation and Fair Hearing Office
fair hearings call (916) 558-5860 (voice) or (916)
c/o Department of Rehabilitation
558-5862 (TTY) or visit the DOR webpage at
Legal Affairs
http://www.dor.ca.gov/RAB/index.html
721 Capitol Mall, Sacramento, CA 95814-4702
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