Arizona DDD Eligibility

Administrative Review Request Template

This optional template can help organize a written request after an initial DDD eligibility denial. It is not an official government form and isn't legal advice. A special form isn't required. Follow the deadline and submission instructions in the denial letter.

Where to request review

DDD Office of Administrative Review
1789 W. Jefferson Street, Mail Drop 2HE5
Phoenix, Arizona 85007

Phone: 602-771-8163 or 1-844-770-9500, option 3
Email: DDDOfficeofCompliance@azdes.gov

Confirm the current contact information and use the instructions printed on the denial notice.

Request for Administrative Review

Date: __________________________________________

Applicant's full name: ______________________________

Date of birth: ____________________________________

DDD or application number, if known: __________________

Name of parent, guardian, or representative, if applicable:
__________________________________________________________

Phone and email:
__________________________________________________________

Date shown on the denial notice: ______________________

Request

I am requesting Administrative Review of DDD's decision denying eligibility. I disagree with the decision for the reasons described below and ask DDD to reconsider the determination using the information and records I am providing.

Reason I disagree with the decision

Functional areas that should be reconsidered

Check every area addressed by the records and examples you are submitting.

☐ Receptive and expressive language☐ Learning☐ Self-direction☐ Self-care☐ Mobility☐ Capacity for independent living☐ Economic self-sufficiency

Everyday support needs and specific examples

Describe what the person can't do independently or safely, the type and frequency of assistance needed, what happens without support, and how functioning differs from age expectations.

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________________________________________________________________
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Documents included

☐ Denial notice☐ Diagnostic evaluation☐ IEP, MET, or school records☐ Adaptive behavior testing☐ Medical records☐ Speech, occupational, or physical therapy records☐ Statements describing daily support needs☐ Other: ______________________________

Signature: ______________________________ Date: ______________