I received via e-mail an interesting letter.  It is a sample of a possible tier letter of appeal template.  The question posed by the author of the e-mail was:  Do you think this will work?  I’m not sure who the author of the sample letter is.   Every support coordinator that responded felt this was a workable letter of appeal.

You need to know that this letter was probably not written by a lawyer but an advocate.  I am not a lawyer and I don’t give legal advice.  However, if you believe this appeal letter will work, you should get the advice of your support coordinator and you are free to use it and/or pass it on.  Again, I am not a lawyer and I don’t give legal advice.  I just feel it’s important to pass on information I receive that I think may benefit you.



                                                                                    Name of Recipient

                                                                                    Address of Recipient

                                                                                    City, Florida, Zip Code

                                                                                    Phone Number

                                                                                    Personal Representative

                                                                                    Phone of Personal Rep.


VIA FACSIMILE [(850) 410-0665] AND U.S. MAIL


Agency Clerk

Agency for Persons with Disabilities

4030 Esplanade Way, Suite 380

Tallahassee, FL  32300-0950


                        Re: Request for Administrative Hearing – Tier Assignment


Dear Agency Clerk:


            Please treat this letter as a request for an administrative hearing under the authority of Florida law at Sections 120.569 and 120.57, Florida Statutes, as I am adversely affected by decisions made by the Agency or its agents.  Specifically, I am contesting the actions taken by the Agency for Persons with Disabilities, including but not limited to findings of fact made by the Agency when assigning me to Tier ___ under the Agency’s Developmental Services tier waiver system.  I believe the facts show that I should have been assigned to Tier ____.


1.      My name and address is listed above.  I am being represented in this matter by ________________, Esq.  Her address is ____________________________; her phone number is _________________.  An authorization for her to serve on my behalf is attached.  Please serve all pleadings and other documents on her.


2.      As noted above, I am requesting an administrative hearing on the matter of my assignment to Tier ____ in the Agency’s waiver system.


3.      The following facts and circumstances lead me to believe my assignment to Tier ____ was in error, and I should have been assigned to Tier _____.  

·        For the past ____ year(s), I have received the following services

(List here) ___________________________________________




·        All of these services were judged medically necessary by the Agency and its agents.

·        My condition remains unchanged, or worse, and I continue to be in need of these services.

·        The total annual cost of these services was $__________________.

·        By comparison, my assignment to Tier _____ means that I will have a limit of $__________ on the medically necessary services provided to me.  This limit will require that I reduce or terminate services I am currently receiving.

·        The reduction or termination of services provided to me will cause my condition to worsen, potentially place me in danger to myself or those around me, and put me at risk for institutional placement.

·        The reduction or termination of services provided to me is not justified by any medical finding made by the Agency – indeed, I was not even examined by a medical professional prior to this assignment to Tier ___.


4.      A copy of the Agency’s tier assignment notice to me is attached.


5.      I received a copy of the Agency’s notice assigning me to Tier ____ on

___________, 2008.


            6.  A document authorizing _________________________ to represent me in

     this matter is attached.


            I have filed this request for a hearing on the matter of my assignment to Tier ____ within 10 days of receiving such notice.  As a result, I expect my services will continue to be provided, as required under federal law.  If this is not the case, and my services are or have been reduced or terminated, please inform my representative immediately.






                                    Signed:  Recipient (or authorized representative for recipient)



Attachments: (2)

            Agency Notice of Assignment to Tier ____

            Authorization of Representative













Name of recipient




(Do not forget to place a copy of the notice here!

. . . and throw this sheet of paper away.)