DEPARTMENTOF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE RECONSIDERATION REQUEST FORM 1. Beneficiarys 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. MYREASONS 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. Requesters Name: ______________________________________________________________________ 9. Requesters Relationship to the Beneficiary: _________________________________________________ 10. Requesters Address: ____________________________________________________________________ ________________________________________________________________________ _____________ 11. Requesters T elephone Number:___________________________________________________________ 12. Requesters Signature: ___________________________________________________________________ 13. Date Signed:________________________________________________________________________ __ 14.o I have evidence to submit. (Attach such evidence to this form.) o I donot 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) American LegalNet, Inc. www.USCourtForms.com