MEDICARE REDETERMINATION REQUEST FORM DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES1. 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 initial determination notice (Ifyoureceivedyourinitialdeterminationnoticemorethan120daysago,includeyourreasonfornotmakingthisrequestearlier.)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. I have evidence to submit. (Attach such evidence to this form.) I do not have evidence to submit.NOTICE: Anyone who misrepresents or falsifies essential information requested by this form may uponconviction be subject to fine or imprisonment under Federal Law.Form CMS-20027 (05/05) EF 0444433344444444444444444444444444444445/2005American LegalNet, Inc. www.USCourtForms.com