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Attachment G- Request for Fair Hearing Attachment H- Withdrawal of Request for Hearing Attachment I- Overpayment Letter Attachment J- Overpayment Letter #2 Attachment K- Overpayment Letter #3 Attachment L- Overpayment Letter with IPV Attachment M - Promissory Note and Confessed Judgment form Attachment N- Administrative Disqualification Hearing Waiver Attachment O- Disqualification Consent Agreement Attachment P- Administrative Disqualification Hearing Phamplet Attachment Q- Administrative Hearing Decision Attachment R- Consent to Release Information Attachment S- Point in Time Waiver Attachment T- Physician Certification form Attachment U - DHCD Referral Form Attachment V- Crisis Declaration Form Attachment W- Office of Administrative Hearing/Transmittal Attachment X- Logon Request Form Attachment Y- FIA Document Disposal guidelines Attachment Z- Outreach Log Attachment AA - MCCU Debt Referral Attachment AB - Advance Notice of Administrative Disqualification Hearing Attachment AC - OAH Transmittal Form for DHS Updated May 2025

Updated May 2025