State Fair Hearing Forms

Member Forms

State Fair Hearing Request Form for a Member regarding Eligibility or Fee for Service Decision:
Eligibility or FFS Beneficiary - Request for Medicaid Fair Hearing

State Fair Hearing Request Form for a Member regarding a Healthcare Service Decision by a MCO:
KanCare Member_Request for Medicaid Fair Hearing

Notice of Withdrawal of Appeal

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

Notice of Withdrawal of Appeal