Get Hearing Request Form (dma-9051) - Nc Dhhs Online Publications ... - Info Dhhs State Nc

This guide provides step-by-step instructions for filling out the Hearing Request Form (DMA-9051) required for appealing a nursing facility's notice of transfer or discharge. Users of all experience levels can follow this comprehensive guide to ensure their submission is complete and accurate.

Follow the steps to properly complete the hearing request form.

1. Press the ‘Get Form’ button to access the Hearing Request Form (DMA-9051) and open it in your digital editor.
2. Fill in the resident's name in the designated field, ensuring it matches the information on the notice of transfer or discharge.
3. Complete the facility name by entering the name of the nursing facility handling the resident's case.
4. Input the date of the transfer or discharge notice as provided to you. This is essential for verifying your request's timeliness.
5. Enter the date scheduled for the transfer or discharge in the appropriate field, as per the provided notice.
6. In the section addressed to the hearing officer, clearly indicate your intention to appeal the transfer/discharge notice.
7. Select your preferred method for the hearing: either by telephone or in person in Raleigh, NC, by checking the corresponding box.
8. Provide the name of the person requesting the hearing and complete their address. Ensure this matches the records held by the facility.
9. Fill in the telephone number of the person requesting the hearing for further communications.
10. Sign and date the form. If the resident is not signing, ensure that the signature is from a family member or legal representative.
11. Attach a copy of the notice of transfer or discharge as required by the form instructions.
12. Submit the completed form by mailing it to the DHHS Hearing Office at the specified address, or send it via facsimile to the provided number.

Complete your Hearing Request Form online today to ensure you meet the submission deadline.