The document is a request for a State Fair Hearing. It instructs the reader to include their name, address, phone number, Social Security Number, and reason for requesting the hearing in their letter. It also notes that if someone is assisting with the request, their contact information should be included as well. It states that a decision could take up to 90 days, but if waiting that long poses a health risk, a doctor's letter explaining this should be provided to request an expedited hearing within 3 working days instead.