Form to Initiate Review

(1) An applicant for or recipient of services from the Commission who is dissatisfied with any specific decision of the Commission with regard to the furnishing or denial of services under any of the programs administered by the Commission may file a request for review and redetermination of that decision by letter addressed to the Deputy Commissioner no later than 30 days after receipt of written or oral notice of that decision. (2) The letter shall contain the: (a) Name, address and telephone number of the person seeking review; (b) Specific service claimed to have been denied or furnished in an unsatisfactory manner; (c) Name of the Commission employee directly responsible for the decision being grieved; and (d) Signature of the individual seeking review or of that person’s authorized representative. (3) When an individual is represented by another party, a letter shall be accompanied by a written statement signed by the complainant identifying the representative and authorizing the Commission to receive all information from relevant entities and to release all information in its possession which relates to the individual requesting the review. No information shall be disclosed by the Commission without such authorization.