Form HW 0406 Fair Hearing Rights and Request Form - Idaho

Form HW0406 is a Idaho Department of Health and Welfare form also known as the "Fair Hearing Rights And Request Form". The latest edition of the form was released in January 1, 2017 and is available for digital filing.

Download a PDF version of the Form HW0406 down below or find it on Idaho Department of Health and Welfare Forms website.

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Contact the Department
Mail:
P.O. Box 83720, Boise, ID 83720-0026
Phone:
1-877-456-1233 or 1-208-332-7205 (TTY)
Fax:
866-434-8278 (Toll Free)
Email:
mybenefits@dhw.idaho.gov
Fair Hearing Rights and Request Form
You have the right to ask for a hearing if you disagree with the Department's action. You have 90 days to ask for a hearing for Food Stamps and
30 days for all other programs, such as Health Coverage Assistance, Cash Assistance for the Aged, Blind or Disabled, Idaho Child Care, and
Temporary Assistance for Families in Idaho. These timeframes start the date the Department gave or mailed you a notice.
Please be advised that a review of eligibility will be assessed for all members of the household at the time this appeal is considered.
To request a hearing or a legal aid referral, call (877) 456-1233 or email us at mybenefits@dhw.idaho.gov. At the hearing, you may represent
yourself, use legal counsel, a relative, a friend, or other spokesperson.
If you believe you have been discriminated on the basis of age, color, disability, national origin, gender, religion, race, or political belief, please
see the second page of this form for information.
Complete the information below and send it to the Department to ask for a hearing. If you have
questions or want to file a hearing over the phone, contact us at (877) 456-1233.
Your Contact Information
First Name
Middle Name
Last Name
Date of birth
Case number
Mailing address
City
State
Zip code
Email address
Daytime phone
I disagree with the Department's decision regarding my
Choose to continue or stop benefits
eligibility for the following program(s):
Child Care benefits may not be continued.
Food Stamps
I want to continue receiving benefits until the hearing.
I understand I will have to repay the value of the benefits
Aid to the Aged, Blind or Disabled (AABD) Cash
received between the time the Department took action
and the hearing decision if the hearing officer agrees with
Health Coverage Assistance (HCA)
the Department's action. You must request continuation
Advance Payment of Premium Credit (APTC)
of benefits within 10 days of the date the Department
gave or mailed you a notice.
Idaho Child Care Program (ICCP)
I do not want to continue receiving benefits until the
Temporary Assistance for Families in Idaho (TAFI)
hearing. If the hearing officer does not agree with the
Department's action, I will then receive any benefits to
Other:
which I am entitled.
Explain why you disagree with the Department's decision:
Attach another sheet if you need to provide more information than space allows.
HW0406 | REV 1/2017
Page 1 of 2
Contact the Department
Mail:
P.O. Box 83720, Boise, ID 83720-0026
Phone:
1-877-456-1233 or 1-208-332-7205 (TTY)
Fax:
866-434-8278 (Toll Free)
Email:
mybenefits@dhw.idaho.gov
Fair Hearing Rights and Request Form
You have the right to ask for a hearing if you disagree with the Department's action. You have 90 days to ask for a hearing for Food Stamps and
30 days for all other programs, such as Health Coverage Assistance, Cash Assistance for the Aged, Blind or Disabled, Idaho Child Care, and
Temporary Assistance for Families in Idaho. These timeframes start the date the Department gave or mailed you a notice.
Please be advised that a review of eligibility will be assessed for all members of the household at the time this appeal is considered.
To request a hearing or a legal aid referral, call (877) 456-1233 or email us at mybenefits@dhw.idaho.gov. At the hearing, you may represent
yourself, use legal counsel, a relative, a friend, or other spokesperson.
If you believe you have been discriminated on the basis of age, color, disability, national origin, gender, religion, race, or political belief, please
see the second page of this form for information.
Complete the information below and send it to the Department to ask for a hearing. If you have
questions or want to file a hearing over the phone, contact us at (877) 456-1233.
Your Contact Information
First Name
Middle Name
Last Name
Date of birth
Case number
Mailing address
City
State
Zip code
Email address
Daytime phone
I disagree with the Department's decision regarding my
Choose to continue or stop benefits
eligibility for the following program(s):
Child Care benefits may not be continued.
Food Stamps
I want to continue receiving benefits until the hearing.
I understand I will have to repay the value of the benefits
Aid to the Aged, Blind or Disabled (AABD) Cash
received between the time the Department took action
and the hearing decision if the hearing officer agrees with
Health Coverage Assistance (HCA)
the Department's action. You must request continuation
Advance Payment of Premium Credit (APTC)
of benefits within 10 days of the date the Department
gave or mailed you a notice.
Idaho Child Care Program (ICCP)
I do not want to continue receiving benefits until the
Temporary Assistance for Families in Idaho (TAFI)
hearing. If the hearing officer does not agree with the
Department's action, I will then receive any benefits to
Other:
which I am entitled.
Explain why you disagree with the Department's decision:
Attach another sheet if you need to provide more information than space allows.
HW0406 | REV 1/2017
Page 1 of 2
Additional Rights and Services
Español
ATENCIÓN: si habla español, tiene a su disposición
(Spanish)
servicios gratuitos de asistencia lingüística. Llame
Available to You
al 1-800-926-2588 (TTY: 1-208-332-7205).
注意:如果您使用 繁體中文,您可以免費獲得語
繁體中文
言援助服務。請致電 1-800-926-2588(TTY:
IMPORTANT: The Department of Health and Welfare offers
(Chinese)
the following services free to you; please ask if you need the
1-208-332-7205)。
following assistance to communicate more effectively with
Srpsko-
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski,
us:
hrvatski
usluge jezičke pomoći dostupne su vam besplatno.
*Assistance in understanding this form
(Serbo-
Nazovite 1-800-926-2588 (TTY- Telefon za osobe sa
*Accommodation for a disability
Croatian)
oštećenim govorom ili sluhom: 1-208-332-7205).
*Language Interpreter
한국어
주의: 한국어를 사용하 시는 경우, 언어 지원 서비스
To access any of these services, please call: (877) 456-1233
(Korean)
를 무료로 이용하실 수 있습니다. 1-800-926-2588 (TTY:
or (888) 791-3004 for those with a hearing impairment.
1-208-332-7205)번으로 전화해 주십시오.
ने प ाल�
ध्यान �दन ु ह ोस ्: तपार् इ ं ल े ने प ाल� बोल्न ु ह ु न् छ भने
In accordance with federal law and U.S. Department of
(Nepali)
तपार् इ ं क ो �निम्त भाषा सहायता से व ाहरू �नःश ु ल् क
Agriculture (USDA) and U.S. Department of Health and Human
रूपमा उपलब्ध छ । फोन गर?् न ु ह ोस ्
Services (HHS) policy, the Department is prohibited from
1-800-926-2588 (�ट�टवाइ: 1-208-332-7205) ।
discriminating, excluding people, or treating them differently
on the basis of race, color, national origin, sex, age, or disability.
Tiếng Việt
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ
Under the Food Stamp Act and USDA policy, discrimination is
trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
(Vietnamese)
prohibited also on the basis of religion or political beliefs. If you
1-800-926-2588 (TTY: 1-208-332-7205).
believe you have been discriminated against, please contact
HHS, USDA or IDHW at:
‫اﻟﻌﺮﺑﻴﺔ‬
‫ﻣﻠﺤﻮﻇﺔ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ، ﻓﺈن ﺧﺪﻣﺎت اﳌﺴﺎﻋﺪة اﻟﻠﻐﻮﻳﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ‬
:‫ﺑﺎﳌﺠﺎن. اﺗﺼﻞ ﺑﺮﻗﻢ 1-008-629-8852 )رﻗﻢ ﻫﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ‬
(Arabic)
U.S. Department of Health and Human Services
7205-332-208-1).
Room 506F, 200 Independence Ave, SW
ACHTUNG: Wenn Sie Deutsch sprechen, stehen
Deutsch
Washington, D.C. 20201
Ihnen kostenlos sprachliche Hilfsdienstleistungen
(German)
(800) 368-1019 (Voice)
zur Verfügung. Rufnummer: 1-800-926-2588 (TTY:
1-208-332-7205).
USDA Office of Adjudication
Tagalog
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari
1400 Independence Ave. S.W.
(Tagalog/
kang gumamit ng mga serbisyo ng tulong sa wika
Washington, D.C. 20250-9410
Filipino)
nang walang bayad. Tumawag sa 1-800-926-2588
(800) 795-3272 (Voice)
(TTY: 1-208-332-7205).
(800) 877-8339 (TTY)
Русский
ВНИМАНИЕ: Если вы говорите на русском языке,
Idaho Department of Health and Welfare
(Russian)
то вам доступны бесплатные услуги перевода.
Civil Rights Manager
Звоните 1-800-926-2588 (телетайп:
1-208-332-7205).
P.O. Box 83720
Boise, ID 83720-0036
Français
ATTENTION: Si vous parlez français, des services
(French)
d'aide linguistique vous sont proposés
For more information about the Department of Health and
gratuitement. Appelez le 1-800-926-2588 (TTY:
Welfare’s nondiscrimination policy, visit our website:
1-208-332-7205).
healthandwelfare.idaho.gov/AboutUs/Discrimination.aspx
注意事項:日本語 を話される場合、無料の言語
日本語
支援をご利用いただけま
(Japanese)
す。1-800-926-2588(TTY:1-208-332-7205)ま
で、お電話にてトご連絡ください。
Română
ATENȚIE: Dacă vorbiți limba română, vă stau la
(Romanian)
dispoziție servicii de asistență lingvistică, gratuit.
Sunați la 1-800-926-2588 (TTY: 1-208-332-7205).
ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa
Ikirundi
(Bantu-
serivisi zo gufasha mu ndimi, ku buntu. Woterefona
Kirundi)
1-800-926-2588 (TTY: 1-208-332-7205).
‫ ﻓﺎرﺳﯽ‬
‫ﻧﺎﮔﯿﺎر ﺗﺮوﺻﺐ ﯾﻨﺎﺑﺰ ﺗﺎﻟﯿﮭﺴﺖ ،دﯾﻨﮏ ﯾﻢ وﮔﺘﻔﮓ ﯾﴪاف ﻧﺎﺑﺰ ﮬﺐ‬
(Farsi)
‫رﮔﺎ :ﮬﺠﻮت1-008-629-8852 ﺳﺎﻣﺖ دﯾﺮﯾﮕﺐ. اﻣﺶ ﯾﺎرب‬
(TTY: 1-208-332-7205 ) ‫ف ﯾﻢ دﺷﺎب .اب‬
HW0406 | REV 1/2017
Page 2 of 2

Download Form HW 0406 Fair Hearing Rights and Request Form - Idaho

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