STATE OF CALIFORNIA OFFICE OF ADMINISTRATIVE HEARINGS TDD/TYY 800-735-2929 2349 GATEWAY OAKS DR., SUITE 200 SACRAMENTO, CA 95833 Phone 916-263-0500 FAX 916-376-6349 320 WEST FOURTH STREET, ROOM 630 LOS ANGELES, CA 90013 Phone 213-576-7200 FAX 916-376-6324 1515 CLAY STREET, SUITE 206 OAKLAND, CA 94612 Phone 510-622-2722 FAX 916-376-6323 1350 FRONT STREET, ROOM 3005 SAN DIEGO, CA 92101 Phone 619-525-4475 FAX 916-376-6325 REHABILITATION SERVICES REQUEST TO SET FAIR HEARING / MEDIATION (Cal. Code Regs., tit. 1, § 1018) DATE CLAIMANT NAME NAME OF DISTRICT OFFICE DISTRICT OFFICE ATTORNEY/REPRESENTATIVE Name, Address, Telephone, E-mail & Fax Nos. CLAIMANT Name, Address, Telephone, E-mail & Fax Nos. CLAIMANT AUTHORIZED REPRESENTATIVE /ATTORNEY Name, Address, Telephone, E-mail & Fax Nos. FROM: OAH CASE NO. Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail MEDIATION ONLY DOES DOR ACCEPT MEDIATION: TIME ESTIMATE FOR FAIR HEARING HOURS DAYS DATES PREFERRED (ALL PARTIES) PLEASE LIST EACH SEPARATELY ­ USE ADDITIONAL SHEETS IF NECESSARY FAIR HEARING ONLY ACCEPTED DECLINED INTERPRETER NEEDED? LANGUAGE: HEARING LOCATION Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail FAIR HEARING AND MEDIATION TIME ESTIMATE FOR MEDIATION HOURS DAYS DATES UNAVAILABLE (ALL PARTIES) DATES COORDINATED WITH ALL PARTIES? YES NO ADDITIONAL COMMENTS AND/OR INSTRUCTIONS WHICH WOULD AFFECT CALENDARING, REQUEST FOR ACCOMMODATION, ETC. NOTICE: This is not a reservation of dates. Completion of this form does not guarantee that you will receive the hearing dates requested. Dates are subject to availability at the time a Request to Set or other calendar request is processed by OAH. For more information visit www.dgs.ca.gov/OAH American LegalNet, Inc. www.FormsWorkFlow.com