Section 4702.6.

"Hearing request form" means a document that shall include the name, address, and birth date of the claimant, date of request, reason for the request, and name, address, and relationship to the claimant of the authorized representative, if any, and whether the claimant is a participant in the medicaid home and community-based waiver. The hearing request form shall also indicate whether the claimant or his or her authorized representative is requesting mediation. A copy of the appointment of the authorized representative, by the claimant or the area board if any, shall also be included.

(Amended by Stats. 1998, Ch. 310, Sec. 46. Effective August 19, 1998.)