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Medicare Reconsideration Request Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Medicare Reconsideration Request Form, CMS-20033, Official Federal Forms Centers For Medicare And Medicaid Services,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE RECONSIDERATION REQUEST FORM
1. Beneficiary’s Name:_____________________________________________________________________
2. Medicare Number: ______________________________________________________________________
3. Description of Item or Service in Question: __________________________________________________
4. Date the Service or Item was Received: _____________________________________________________
5. I do not agree with the determination of my claim. MY REASONS ARE:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6. Date of the redetermination notice__________________________________________________________
(If you received your redetermination more than 180 days ago, include your reason for not making this request earlier.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
7. Additional Information Medicare Should Consider: ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
8. Requester’s Name:______________________________________________________________________
9. Requester’s Relationship to the Beneficiary: _________________________________________________
10. Requester’s Address: ____________________________________________________________________
_____________________________________________________________________________________
11. Requester’s Telephone Number: ___________________________________________________________
12. Requester’s Signature: ___________________________________________________________________
13. Date Signed: __________________________________________________________________________
14. J I have evidence to submit. (Attach such evidence to this form.)
J I do not have evidence to submit.
15. Name of the Medicare Contractor that Made the Redetermination:________________________________
NOTICE: Anyone who misrepresents or falsifies essential information requested by this form may upon
conviction be subject to fine or imprisonment under Federal Law.
Form CMS-20033 (05/05) EF (045/2005)
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