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Home and Community Based Services Manual

6.00, Appendix 8 Agency Witness List Instructions

Home and Community Based Services Manual


6.00, Appendix 8 Agency Witness List Instructions

The Agency Witness List shall be utilized by Division of Senior and Disability Services (DSDS) staff to identify agency witness contact information and availability for purposes of scheduling a Home and Community Based Services (HCBS) administrative hearing.

INSTRUCTIONS 

Enter witness information, including name, phone, and alternative phone (where applicable), e-mail, and availability. 

  • For availability, enter dates and times during which the witness is available to attend the hearing. These dates should cover at least the next thirty (30) business days from date this form is completed. 

DISTRIBUTION 

Upon completion, the Agency Witness List shall be included with the Adverse Action Notice (HCBS-12) and the completed Application for State Hearing (HCBS-12a) forwarded to the participant/guardian, DSDS HCBS Hearing Representative and the Department of Social Services, Division of Legal Services.

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