ODA Form 1117 "Notice of Proposed Action and Opportunity for Hearing" - Ohio

What Is ODA Form 1117?

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

Form Details:

  • Released on April 1, 2012;
  • The latest edition provided by the Ohio Department of Aging;
  • 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 ODA Form 1117 by clicking the link below or browse more documents and templates provided by the Ohio Department of Aging.

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Download ODA Form 1117 "Notice of Proposed Action and Opportunity for Hearing" - Ohio

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Ohio Department of Aging
Notice of Proposed Action and Opportunity for Hearing
Name:
Street Address:
Client Identification Number:
Program:
[Blank]
City, State, and Zip Code:
County:
Mailing Date:
The Department of Aging (ODA) is proposing to take the following action(s) with regard to your
application for, or continued enrollment in the state-funded program identified below:
The Department of Aging is proposing to deny your application for enrollment into the state-funded
[Blank]
[Blank]
program under section(s)
of the Revised Code.
[Blank]
As a condition to your continued enrollment in the state-funded
program, the
Department is proposing that you will have to pay a monthly patient liability amount of $
This monthly payment is due on
. The payment must be made
to
.
Effective on
, the Department is proposing the following changes to the services
[Blank]
that you receive through the state-funded
program:
[Blank]
The Department is proposing to terminate your enrollment in the state-funded
program, effective on
. Your last day of service will be:
.
The Department of Aging’s reasons for the proposed action are:
The state statutes and regulations supporting the Department of Aging’s proposed action(s) are:
If you disagree with the action(s) being proposed by the Department, you must sign this form below
th
and return the form to:
Director, Ohio Department of Aging, 50 W. Broad Street, 9
Floor, Columbus,
Ohio 43215.
Your signature on this form must be received by the Department of Aging within 30
days of the date on which the PASSPORT Administrative Agency mailed this form to you. DO
NOT SEND THIS FORM TO YOUR LOCAL PASSPORT ADMINISTRATIVE AGENCY OR CASE
MANAGER. If this form is not received within 30 days of the date the PASSPORT Administrative Agency
mailed this notice to you, your request for a hearing will be denied.
Signature:
Telephone Number:
Please Continue Reading the Back/Next Page of this Document
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ODA Form 1117
Rev 4/2012
Ohio Department of Aging
Notice of Proposed Action and Opportunity for Hearing
Name:
Street Address:
Client Identification Number:
Program:
[Blank]
City, State, and Zip Code:
County:
Mailing Date:
The Department of Aging (ODA) is proposing to take the following action(s) with regard to your
application for, or continued enrollment in the state-funded program identified below:
The Department of Aging is proposing to deny your application for enrollment into the state-funded
[Blank]
[Blank]
program under section(s)
of the Revised Code.
[Blank]
As a condition to your continued enrollment in the state-funded
program, the
Department is proposing that you will have to pay a monthly patient liability amount of $
This monthly payment is due on
. The payment must be made
to
.
Effective on
, the Department is proposing the following changes to the services
[Blank]
that you receive through the state-funded
program:
[Blank]
The Department is proposing to terminate your enrollment in the state-funded
program, effective on
. Your last day of service will be:
.
The Department of Aging’s reasons for the proposed action are:
The state statutes and regulations supporting the Department of Aging’s proposed action(s) are:
If you disagree with the action(s) being proposed by the Department, you must sign this form below
th
and return the form to:
Director, Ohio Department of Aging, 50 W. Broad Street, 9
Floor, Columbus,
Ohio 43215.
Your signature on this form must be received by the Department of Aging within 30
days of the date on which the PASSPORT Administrative Agency mailed this form to you. DO
NOT SEND THIS FORM TO YOUR LOCAL PASSPORT ADMINISTRATIVE AGENCY OR CASE
MANAGER. If this form is not received within 30 days of the date the PASSPORT Administrative Agency
mailed this notice to you, your request for a hearing will be denied.
Signature:
Telephone Number:
Please Continue Reading the Back/Next Page of this Document
1 of 2
ODA Form 1117
Rev 4/2012
You Have a Right to be Notified of the Proposed Action(s):
The purpose of this notice is to inform you about the action the Ohio Department of Aging (“ODA”) is
proposing to take with regard to your application for services under, or enrollment in, a state-funded
program. If you do not understand this proposed action, you may contact your case manager. After
discussing this matter with your case manager, it is possible that that you will agree with the proposed
action(s), or that ODA will decide against taking the proposed action(s).
Your Case Manager or Assessor Is:
Your Case Manager’s or Assessor’s Telephone Number Is:
You Have an Opportunity to Challenge the Proposed Action at a State Hearing:
Whether or not you contact your case manager, you have an opportunity to challenge the proposed
action(s) at a state hearing in Columbus, Ohio - but only if you submit your written request for a hearing
in a timely manner. (A written request for an administrative hearing is submitted in a timely manner by
you if it is received by the Director of the Ohio Department of Aging within 30 days of the date on which
the notice of proposed action was mailed to you by your PASSPORT Administrative Agency.)
If your request for a hearing is filed in a timely manner, the Department will postpone taking the proposed
action(s) against you, and will instead schedule a hearing to take place in Columbus, Ohio. You may
appear at the hearing in person, and/or be represented at the hearing by an attorney licensed to
practiced law in Ohio. At the hearing, you or your attorney may present evidence and examine any
witnesses appearing for or against you. If you do not wish to appear at the hearing in person, you or
your attorney may submit your position, arguments, or contentions in writing prior to the start of the
hearing.
A representative of ODA will also attend the hearing, and will present ODA’s reasons for the proposed
action. An independent hearing officer retained by ODA will prepare a report and recommendation to the
Director of ODA in accordance with Chapter 119. of the Revised Code. The Director of ODA will issue a
final decision, called a “Final Order,” in the matter. If the Director’s final order adversely affects your
enrollment in the state-funded program, you may be required to pay back any benefits that you were
given, but were not eligible to receive.
To Request an Administrative Hearing:
If you wish to request a state hearing to challenge the proposed action, ODA must receive your signature
on this form within 30 days of the mailing date of this notice. DO NOT SEND THIS FORM TO YOUR
PASSPORT ADMINISTRATIVE AGENCY OR CASE MANAGER.
Further Information:
If you wish information about your eligibility for free legal services, you may contact your local legal aid
office. The telephone number to your local legal aid office can be obtained by calling Ohio State Legal
Services at 1-800-589-5888. If you wish information about your rights as a recipient of state-funded
long-term care services, you may contact your local ombudsman program by calling 1-800-282-1206.
Certified Mail Number:
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ODA Form 1117
Rev 4/2012
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