State Fair Hearing Forms

Member Forms

Provider Forms

State Fair Hearing Request Form for a Provider regarding a Payment Decision by an MCO or KMAP, or a Healthcare Service Decision by a MCO:
Providers - Request for Medicaid Fair Hearing OAH (PDF)
Providers - Request for Medicaid Fair Hearing (WORD)

Notice of Withdrawal of Appeal (PDF)
Withdrawal of State Fair Hearing Request (WORD)