Child Welfare Administrative Hearing Request CF 344 (09/10)



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|Child Welfare Administrative Hearing Request | |

|Check only one: |

| Child and Adolescent Needs and Strengths (CANS) |

|Personal care services |

|Provider name: |

|Home phone: |Cell phone: |Email: |

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|Address: |City: |State: |ZIP code: |

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|Child’s name: |Child’s person ID: |

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|Please state the reasons which you believe payment may have been incorrectly assessed: |

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When there is a reduction of payment, you may request that the higher rate you were receiving prior to the current rate determination continue until the end of the hearing process. However, if at the end of the hearing process, a final order establishes a payment lower than the continued higher rate, you will be required to reimburse the Department of Human Services (DHS) the difference of the two amounts. If you do not choose to continue a previously determined higher rate, and it is determined that the current proposed payment is incorrect, DHS will provide you the difference between the two amounts. Please list the specific items of the CANS or PCSA that you feel were incorrectly rated. NOTE: For CANS appeals, please review the attached document, which lists the CANS items that factor into CANS levels.

| N/A ― Rate not reduced. |

|I do/ I do not request that the prior payment made on behalf of the child placed in my home continue during the hearing process. |

|On behalf of the child, you may be represented at the hearing by any adult, including an attorney. |

|Attorney name (if applicable): |      |

|The administrative law judge may conduct the hearing by phone. If there are multiple requests for hearing, more than one request may be considered at a single |

|hearing. |

|Signature: | | |Date: |      |

Return this form to: By mail: DHS OCWP, 500 Summer St. NE E-67, Salem, OR 97301

By fax: 503-945-5635

Or by email: CANS.PCHearing@state.or.us

(DHS must receive this request within 30 days of the date on your notice and decision letter.)

|Algorithm Elements |Rating |Algorithm Elements |Rating |

|(0-5) | |(6-20) | |

| | | | |

|3 – Substance Exposure | |1 – Suicide Risk | |

|5 – Self-Harm | |2 – Self-Mutilation | |

|6 – Aggression | |3 – Other Self Harm | |

|7 – Sexual Behavior | |4 – Danger to Others | |

|27 – Adjustment to Trauma | |5 - Runaway | |

|36 – Living Situation | |6 - Delinquency | |

|37 – Pre School/Child Care Behavior | |7 - Judgment | |

|39 – Social Functioning | |8 – Fire Setting | |

|40 – Recreation/Play | |9 – Sexual Behavior | |

|41 – Intellectual/Developmental | |33 – Adjustment to Trauma | |

|45 - Communication | |42 – Living Situation | |

|46 - Sleep | |44 – Intellectual/Developmental | |

|52 – Culture Stress | |48 - Legal | |

|53 – Attachment | |51 – Sexual Development/Identity | |

|54 – Attention Deficit/Hyperactivity | |52 – School Behavior | |

|55 – Temperament | |54 – School Achievement | |

|56 – Failure to Thrive | |58 – Culture Stress | |

|57 – Feeding/Elimination | |59 – Attention Deficit/Hyperactivity | |

|58 - Depression | |60 – Depression and Anxiety | |

|59 – Anxiety | |61 - Psychosis | |

|60 – Atypical Behaviors | |62 – Oppositional Behavior | |

| | |63 – Substance Abuse | |

| | |64 – Attachment Difficulties | |

| | |65 – Eating Disturbances | |

| | |66 – Anger Control | |

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