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HealthCheck (EPSDT)
The HealthCheck program provides free check-ups and treatment to Medicaid- and D.C. Healthy Families- eligible children under age 21. The HealthCheck program is very important and can be obtained from any doctor or clinic participating in the Medicaid program. The HealthCheck program also helps in scheduling appointments and providing transportation to the doctor’s office. For help in scheduling appointments and obtaining transportation call 1-800-MOM-BABY. For more information about the program, call (202) 727- 0725.
I hereby declare that this form was discussed with me.
Signature of applicant: Date:
Worker: Telephone No:
All Applicants
You may call your worker, the Office of Administrative Review and Appeals (698-4650), or the Office of Fair Hearings (724-5431) to request a Hearing. In addition, you may request a Hearing through one of the legal service agencies listed below. Should you request a Hearing, the law provides that: 1. You have a right to be represented by legal counsel or by a layperson who is not an employee of the Government of the District of Columbia. 2. You may bring witnesses on your behalf. 3. Reasonable expenses relating to the Hearing, such as transportation costs for you and witnesses, will be paid by the DHS. 4. You may expect a decision within Sixty (60) days of the date of your request. 5. Free legal services are available to you. A list of locations where free legal services may be obtained is listed below.
Free Legal Services
Neighborhood Legal Services 1213 Good Hope Rd., SE (202) 678-2000
Neighborhood Legal Services 3rd Floor 701 Fourth St., NW (202) 682-2735
Legal Aid Society Suite 800 666 11th St., NW (202) 628-1161 Neighborhood Legal Services 1st Floor 701 Fourth St., NW (202) 682-2700
Bread for the City Free Legal Clinic 1525 Seventh St., NW (202) 265-2400
Legal Counsel for the Elderly (for people age 60 and older) 601 E St., NW Building A, 4th Floor (202) 434-2120 For legal help with Medicaid issues, contact:
Terris and Pravlik 1121 12th St., NW Washington, DC 20005 (202) 682-0578
DHS Form 1400 (12/83) Distribution: Original to Customer, Copy to Case Record Rev (1/03)