Withdrawal Request for State Hearing or Administrative Appeal

If you have resolved your state hearing or administrative appeal issue with the county agency, state administrative agency, or managed care plan and would like to withdraw your state hearing, please complete the information below.

Information Needed for Withdrawing Your Appeal: (* Indicates required field)

Case number or appeal number:

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone Number with Area Code:

Email Address:

Explain why you would like to withdraw your hearing: (1000 character limit)

By typing your electronic signature below, you are saying you are the person requesting the Bureau of State Hearings to withdraw your state hearing request for you. Individuals who you have given the right to represent you and sign on your behalf must be designated as an authorized representative in our Hearings and Appeals Tracking System (HATS X) in order to process this request. Otherwise, the authorized representative will need to submit the withdrawal by following one of the methods below, along with authorization to represent verification.

Signed (type your full name):

Date:

[None]

Here are the other ways to withdraw your state hearing request or administrative appeal request:

    Email – BSH_Prehearing_Resolution@jfs.ohio.gov. In the subject, put "Withdraw".
    Fax – (614) 728-9574
    Mail – ODJFS Bureau of State Hearings, P.O. Box 182825, Columbus, Ohio 43218-2825.
    Drop off this form to your caseworker – It is much better to send the request by one of the ways listed above.

You can ask your local Legal Aid program for free help with your case. Contact your local Legal Aid office by phoning 1-866-LAW-OHIO (1-866-529-6446) or by searching the Legal Aid directory at http://www.ohiolegalhelp.org/find-legal-help/.