Form 1505, Request for Due-Process Hearing and/or Mediation

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Effective Date: 8/2019


Updated: 8/2019


Form 1505 is completed by a participant to initiate the DRS and DBS process for a due process hearing or mediation.

Copies and Distribution



The original form is maintained in the HHS Legal Hearings file for three years following the end of the fiscal year, in accordance with the HHS Retention Schedule.

Detailed Instructions

Hearing Request Information — Choose one of the determinations or concerns listed.
Authorization — The participant must sign.