Part A Pre-Hearing Input Record Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Part A Pre-Hearing Input Record Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Part A Pre-Hearing Input Record, CMS-353, Official Federal Forms Centers For Medicare And Medicaid Services,
PAR T A PRE-HEARING INPUT RECORD RECORD IDENTIFIER H.I. CLAIM NUMBER ADMISSION/HHA DATE (MMDDYYYY) B SURNAME GIVEN NAME PROVIDER NUMBER REQUESTED BY HEARING FILED - (MMDDYYYY) BLANK - BENEFICIARY 1. ATTORNEY 3. PROVIDER 2. RELATIVE 4. OTHER RECON. INTER. 5011 REC. DATE. - (MMDDYYYY) DEV. REQ. DATE - (MMDDYYYY) REFERRED TO RO DATE - (MMDDYYYY) RETURNED TO INT. DATE - (MMDDYYYY) DECISION MODIFIED 1. YES 2. NO HEARING SENT OHA DATE - (MMDDYYYY) HEARING OFFICE American LegalNet, Inc. www.USCourtForms.comForm CMS-353 (6-86)