Administrative Hearing Request Packet - Indiana

PREPARATION GUIDE — NOT A UNIVERSAL AGENCY FORM

Indiana does not use one universal “administrative hearing request” for every agency
action. Start with the agency's order and notice. Identify the law creating the review
right, the correct petition recipient, deadline, form, filing method, and agency-specific
rules. Use this guide only after confirming that the Indiana Administrative Orders and
Procedures Act (AOPA), IC 4-21.5, governs the matter.

Indiana Petition for Administrative Review — Preparation Packet

1. Mandatory filing gate

Agency: [________________________________]

Program, board, or division: [________________________________]

Agency order or determination: [________________________________]

Order date: [__/__/____]

Date personally served: [__/__/____]

Date deposited in U.S. mail, if mailed: [__/__/____]

Date actually received: [__/__/____]

Agency docket, license, claim, or reference number: [________________________]

Attach the complete order and every page of its review-rights notice.

Source of review right

☐ IC 4-21.5-3-4 order

☐ IC 4-21.5-3-5 order

☐ IC 4-21.5-3-6 order

☐ Emergency or temporary order under IC 4-21.5-4

☐ Agency- or program-specific statute: [________________________________]

☐ Agency rule: [________________________________]

☐ AOPA does not apply or another exclusive review procedure controls — stop and use the
correct procedure.

Notice audit

For orders governed by IC 4-21.5-3-4, -5, or -6, the notice generally must briefly
describe the order and explain the available administrative-review procedure and time
limit under IC 4-21.5-3-7.

Procedure stated in notice: [________________________________]

Deadline stated in notice: [________________________________]

Recipient stated in notice: [________________________________]

Required form or portal: [________________________________]

Required filing method: [________________________________]

Agency-specific rule reviewed: ☐ Yes ☐ No

2. Deadline and filing calculation

For the ordinary orders listed in IC 4-21.5-3-7(a)(3)(A), a qualifying petition is
filed with the agency's ultimate authority within 15 days after notice, or within a
longer period set by another statute. The 15-day period is not a fallback invented for a
notice that says nothing; determine the actual order category and controlling law.

Certain Medicaid hospital determinations under IC 4-21.5-3-6(a)(3) and (4) use a
separate 180-day route filed with the Office of Medicaid Policy and Planning.

Time computation under IC 4-21.5-3-2

• Exclude the triggering day.

• Include the last day unless it is a Saturday, Sunday, state legal holiday, or a day the
  filing office is closed during regular business hours; then continue to the next open
  day.

• For periods shorter than seven days, exclude intervening weekends, state holidays, and
  closed-office days.

• A period based on service begins on the earlier of personal service or deposit of the
  notice in U.S. mail.

• Add three days when the notice is served through U.S. mail.

Base statutory or agency period: [____] days

Triggering service date under § 3-2(c): [__/__/____]

Mail-service addition, if applicable: [____] days

Weekend/holiday/closure adjustment: [________________________________]

Calculated filing deadline: [__/__/____]

Filing completion under IC 4-21.5-3-1(h)

Depending on the authorized method, filing with the ultimate authority or Office of
Administrative Law Proceedings is complete on delivery, U.S.-mail postmark, private-
carrier deposit shown by receipt, or electronic submission. Follow the notice and
agency-specific rule; do not assume email is accepted merely because AOPA recognizes
electronic service and filing.

Authorized method selected: [________________________________]

Proof that will establish the filing date: [________________________________]

3. Petitioner and representative

Petitioner full legal name: [________________________________]

Entity type, if applicable: [________________________________]

Mailing address: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

License, permit, provider, account, or claimant number: [____________________]

Attorney or authorized representative: [________________________________]

Indiana attorney number, if applicable: [________________________________]

Representative address and contact information: [__________________________]

4. Petition for administrative review

BEFORE THE [AGENCY ULTIMATE AUTHORITY]

Agency Reference No.: [________________________________]

Petition

Petitioner requests administrative review of the [ORDER OR DETERMINATION] issued by
[AGENCY] on [__/__/____] and served on [__/__/____].

1. Petitioner is entitled to seek review because:

☐ The order is specifically directed to Petitioner.

☐ Petitioner is aggrieved or adversely affected by the order.

☐ Another law expressly entitles Petitioner to review: [________________________]

2. Facts demonstrating Petitioner's status and injury are:

[____________________________________________________________]

[____________________________________________________________]

3. The petition is timely under [IC 4-21.5-3-7 / OTHER LAW] because:

[____________________________________________________________]

4. Petitioner requests that the agency grant review and assign the matter for the
   proceeding required by controlling law.

5. Petitioner requests the following relief, to the extent the agency may grant it:

☐ Vacate the challenged order.

☐ Modify the order as follows: [________________________________]

☐ Remand for additional agency proceedings.

☐ Grant or restore the license, permit, benefit, status, or other legal interest described
here: [________________________________]

☐ Other authorized relief: [________________________________]

Optional issue statement

An ordinary petition under IC 4-21.5-3-7 must state the facts establishing entitlement
to review. Do not assume every petitioner must file an appellate-style brief with the
initial petition. If the agency's notice, statute, or rule requires an issue statement, use:

Medicaid hospital determinations covered by IC 4-21.5-3-7(a)(2) require the specified
statement of issues. Follow that provision exactly for those matters.

Signature

Petitioner / Counsel: [________________________________]

Signature: [________________________________]

Date: [__/__/____]

Do not add a verification or “penalties of perjury” declaration unless the agency's
notice, controlling statute, or rule requires one.

5. Optional petition for administrative stay

The stay route depends on the order category. IC 4-21.5-3-4(e), -5(h), and -6(e)
provide preliminary-hearing procedures for covered orders when the required review and
stay petitions are filed. The person seeking the stay bears the burden of proof. These
sections do not state one universal four-factor test.

☐ No administrative stay requested.

☐ Stay requested under: [________________________________]

Specific part of the order to be stayed:

[____________________________________________________________]

Facts and law supporting the request under the controlling section and agency rule:

[____________________________________________________________]

Proposed scope and conditions:

[____________________________________________________________]

Check the order's effective date. Orders under §§ 3-4, 3-5, and 3-6 use different
effectiveness and temporary-stay rules.

Emergency or temporary order

If the agency acted under IC 4-21.5-4 without an evidentiary proceeding, a party may
request a hearing; the agency must set it as quickly as practicable, and the ALJ decides
whether the order should be voided, terminated, modified, stayed, or continued.

6. Attachments and service

Attach only what the current procedure permits or requires

☐ Complete agency order and review-rights notice

☐ Agency-required petition or appeal form

☐ Facts supporting entitlement to review

☐ Required issue statement

☐ Petition for stay and supporting material

☐ Representative appearance or authorization

☐ Filing fee or fee-waiver material, if required

☐ Other agency-required document: [________________________________]

Do not attach generic discovery requests or a full merits brief merely because the former
template contained them. Discovery, disclosures, witness lists, and briefing depend on the
agency rules and the ALJ's scheduling or prehearing order. IC 4-21.5-3-8 concerns
sanctions and temporary orders; it is not a general discovery provision.

Service record

IC 4-21.5-3-1 generally permits service by U.S. mail, personal service, email, or another
method approved by the Indiana Trial Rules, subject to other law and the agency's filing
instructions.

Proof retained: [________________________________]

7. What happens after review is granted

• Under IC 4-21.5-3-7(d), a granted petitioner becomes a party and the matter is
  assigned to an ALJ or, when applicable, the Office of Administrative Law Proceedings.

• Prehearing conferences are governed by IC 4-21.5-3-18 and -19, not § 3-7.

• The official agency record matters. Preserve objections and ensure offered evidence and
  excluded-evidence proffers are included as the governing procedure permits.

• A written order under IC 4-21.5-3-27 must rest on record evidence and matters officially
  noticed. The section does not create a universal rule that the agency always bears every
  burden by a preponderance of the evidence.

• Attorney's fees are not a routine prayer. IC 4-21.5-3-27.5 authorizes fees only in its
  specified circumstances.

8. Nonfinal order and final-order checkpoints

Nonfinal ALJ order — IC 4-21.5-3-29

If the ALJ is not the ultimate authority, a party generally must file a written objection
with the ultimate authority within 15 days after the order is served, or a longer period
set by statute, to preserve the objection for judicial review. The writing must identify the
basis with reasonable particularity and be served on all parties and the issuing agency.

Nonfinal order served: [__/__/____]

Objection deadline: [__/__/____]

Objection filed and served: ☐ Yes ☐ No ☐ Not applicable

Final order — IC 4-21.5-3-31

Before court jurisdiction or another agency's jurisdiction attaches, a party may petition
the ultimate authority for a stay. A rehearing may be granted only for newly discovered
material evidence that could not, with due diligence, have been discovered and produced at
the hearing. A motion to correct error or petition for rehearing under § 3-31 tolls the next
administrative-objection or judicial-review period; a new period begins when the motion is
denied or a new order issues. An unresolved motion to correct error or rehearing request is
deemed denied after 30 days if no ruling is made and no hearing is set.

Final order served: [__/__/____]

Post-order motion filed: [__/__/____] / ☐ None

Disposition or deemed-denial date: [__/__/____]

9. Judicial-review handoff — IC 4-21.5-5

This packet is not a court petition for judicial review.

• Exhaust all required administrative remedies. A missed petition, objection, or default
  may waive judicial review.

• Unless another law controls, the verified court petition is due within 30 days after
  notice of the agency action is served, not merely 30 days after the order's printed date.

• Venue, petition contents, service on the ultimate authority, Attorney General, and agency
  parties, and the agency-record deadline are governed by IC 4-21.5-5-6 to -13.

• The person asserting invalidity bears the burden on judicial review. The court decides
  legal questions without deference to the agency's prior interpretation and applies the
  grounds in IC 4-21.5-5-14, including whether the action is unsupported by a preponderance
  of the evidence.

• A court stay under IC 4-21.5-5-9 is a separate verified-petition procedure for eligible
  non-tax matters. It requires a reasonable probability that the order is invalid or illegal
  and an approved bond of at least $500, unless controlling law precludes the stay.

10. Final checklist

☐ Confirmed AOPA and the correct agency-specific procedure apply

☐ Classified the order under the correct section

☐ Calculated time from statutory service, including mail and closure rules

☐ Identified the ultimate authority or other required recipient

☐ Used the required form, portal, and filing method

☐ Stated facts establishing entitlement to review

☐ Included an issue statement only when required

☐ Selected the correct stay route, if any

☐ Served every required person and retained proof

☐ Calendarized prehearing events, nonfinal-order objections, final-order motions, and
judicial review separately

Sources and References

• Indiana Code 2026, IC 4-21.5-3 — Adjudicative Proceedings
• Indiana Code 2026, IC 4-21.5-4 — Emergency and Other Temporary Orders
• Indiana Code 2026, IC 4-21.5-5 — Judicial Review