North Carolina Office of Administrative Hearings - Forms

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Hearings Forms

For filing most contested cases.

NOTE: for Personnel, Child Support, Special Education, or Contested Tax cases, use the appropriate form H-06A to H-06F; for Medicaid cases, use the hearing request form supplied by DHHS.

H-06A
Personnel Petition Form

For filing an appeal of a personnel decision if you are a State employee, local government employee, applicant for employment or former employee covered under Chapter 126 (Personnel Act).

H-06B
Child Support-Tax Intercept Petition Form

For filing a contested case if you have received a Notice of Intent to Intercept your taxes for child support from the North Carolina Department of Health and Human Services and the notice sets out your appeal rights specifically to the Office of Administrative Hearings. (changed DHHS service agent Oct. 5, 2012)

H-06C
Child Support-Distribution Petition Form

For filing a contest case if you are a custodial parent who has received a Notice of Overpayment stating that you were overpaid child support and sets out your appeal rights specifically to the Office of Administrative Hearings. (changed DHHS service agent Oct. 5, 2012)

H-06D
Child Support-Credit Report Petition Form

For filing a contested case if you have received a Child Support Consumer Credit Report Notice that your support obligation information will be forwarded to a credit reporting agency and sets out your appeal rights specifically to the Office of Administrative Hearings. (changed DHHS service agent Oct. 5, 2012)

H-06E
Special Education Petition Form

For filing a contested case (due process) hearing on a special education case. (moved petition reason Manifest Determination to a separate form H-06E-A, January 25, 2012)

H-06E-A
Special Education - Manifestation Determination Petition Form

For filing a contested case (due process) hearing on a special education case regarding a manifestation determination review decision.

H-06F
Contested Tax Petition Form

For filing a contested case if you have received a Notice of Final Determination from the NC Department of Revenue.
Note: this form should not be used for tax intercept issues.

H-OI
Indigent Status Petition Form

For requesting a waiver of the contested case filing fee due to financial hardship.
Note: not all cases require a filing fee - see OAH Case Filing Fee List for a representative list of filing fees.

H-05
Subpoena Forms

Subpoena forms with instructions.

H-08
Designation Of Mediator

H-08A
Report Of Mediator

Mediator's report form.

H-14 Form
Motion By Out-of-State Attorney to Practice Before OAH

H-14 Statute
Motion By Out-of-State Attorney to Practice Before OAH

H-25B
Hearing Tapes/CD Request Form

H-25C
Transcript Request Form

Transcript request form. (clarify service delivery is counted in business days October 19, 2011)

H-25D
Special Education
Transcript Request Form

H-70
Secure Leave Form

Secure Leave form for Attorneys

Service Survey Form

Confidential Survey.

Medicaid Mediation & Hearing Forms

Medicaid Mediation Forms:

Med-01
Medicaid Mediation - General Information

Information about the mediation process for Medicaid appeals.

Med-02
Agreement to Mediate Form

Agreement of both parties to use the mediation process.

Med-04
Report Of Mediation Conference and Memorandum of Agreement

Med-05
Report Of Mediator

Med-06
Recipient Mediation Questionnaire

Med-07
Respondent Mediation Questionnaire

Med-08
Mediation Information Transmittal Cover Sheet

Medicaid Hearings Forms:

Medicaid Hearing Request Form

Contact DHHS if you do not have a hearing request form (do not use an OAH request form).

Med-09
Language Interpreter or Communication Accessibility Request Form

Request for foreign language interpreter, American sign language interpreter or assistive hearing device.

H-25B
Hearing Tapes/CD Request Form

H-25C
Transcript Request Form

Rules Forms

OAH 0300 Notice of Text OAH 0300 Notice of Text	Notice of Text (added Agency 150B-19.1 certification and formally proposed text date, August 2012; minor wording, October 2012)
OAH 0400 Submission for Permanent Rule OAH 0400 Submission for Permanent Rule	Submission for Permanent Rule (Agency 150B-19.1 certification, August 2012)
OAH 0500 Temporary Rule Findings of Need OAH 0500 Temporary Rule Findings of Need	Temporary Rule Findings of Need
OAH 0600 Emergency Rule OAH 0600 Emergency Rule	Emergency Rule Findings of Need
OAH 0700 Publication on the OAH Website OAH 0700 Publication on the OAH Website	Publication on OAH Website
G.S.150B-19.1 Certification of Compliance G.S.150B-19.1 Certification of Compliance	Certification of Compliance with G.S. 150B-19.1
Fiscal Note

Civil Rights Forms

Abbreviated Intake Form

This form will provide preliminary information to the Charge Intake Coordinator in order to assist in the interview and charge filing process.