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Request For Medicare Hearing By An Administrative Law Judge Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF MEDICARE HEARINGS AND APPEALS
REQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE J Part A
Effective July 1, 2005. For use by party to a reconsideration/fair hearing
J Part B
determination issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO)
(Amount in controversy must be $100 or more.)
Send copies of this completed form to:
Original — The FI, Carrier, or QIO that issued the Reconsideration/Fair Hearing Notice
Copy — Appellant
Appellant
(The party appealing the reconsideration determination)
Beneficiary
Provider or Supplier
(Leave blank if same as the appellant.)
Address
(Leave blank if same as the appellant.)
Address
City
State
Area Code/Telephone Number
Zip Code
E-mail Address
City
State
Area Code/Telephone Number
Zip Code
E-mail Address
Document control number assigned by the FI, Carrier, or QIO
Health Insurance (Medicare) Claim Number
FI, Carrier, or QIO that made the reconsideration/fair hearing determination
Dates of Service
From
To
I DISAGREE WITH THE DETERMINATION MADE ON MY APPEAL BECAUSE:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
You have a right to be represented at the hearing. If you are not represented but would like to be, your Office of Medicare Hearings and Appeals
Field Office will give you a list of legal referral and service organizations. (If you are represented and have not already done so, complete form CMS-1696.)
Check
Only One
Statement:
J
J
I wish to have a hearing.
I do not wish to have a hearing and I request that a
decision be made on the basis of the evidence in my
case. (Complete form HHS-723, “Waiver of Right to an
Check
Only One
Statement:
J I have additional evidence to submit.
J I have no additional evidence to submit.
ALJ Hearing.”)
The appellant should complete No. 1 and the representative, if any, should complete No. 2. If a representative is not present to sign, print
his or her name in No. 2. Where applicable, check to indicate if appellant will accompany the representative at the hearing. J Yes J No
1. (Appellant’s Signature)
Date
State
Area Code/Telephone Number
Date
J Attorney
J Non-Attorney
Address
Address
City
2. (Representative’s Signature/Name)
E-mail Address
Zip Code
City
Area Code/Telephone Number
State
Zip Code
E-mail Address
Answer the following questions that apply:
A) Does request involve multiple claims?
J Yes J No
(If yes, a list of all the claims must be attached.)
B) Does request involve multiple beneficiaries?
J Yes J No
(If yes, a list of beneficiaries, their HICNs and the dates of the applicable reconsideration determinations must be attached.)
C) Did the beneficiary assign his or her appeal rights to you as the provider/supplier?
J Yes J No
(If yes, you must complete and attach form CMS-20031. Failure to do so will prevent approval of the assignment.)
D) If there was no assignment, are you a physician being held liable pursuant to 1842(I)(1)(A) of the Social Security Act?
CMS-5011A/B U2 (08/05) EF 08/2005 ATTACH A COPY OF THE RECONSIDERATION/FAIR HEARING DETERMINATION
(IF AVAILABLE) TO THIS COPY.
J Yes J No
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TO BE COMPLETED BY THE OFFICE OF MEDICARE HEARINGS AND APPEALS
Is this request filed timely?
J Yes J No
If no, attach appellant’s explanation for delay. If there is no explanation, send a Notice of Late Filing of Request for ALJ Hearing to the
appellant and representative, if applicable, to request such an explanation.
Request received on
Field Office
Employee
Assigned on
Assigned by
Assigned to
Special response case?
J Yes J No
If yes, explain why and state the targeted adjudication deadline.
_______________________________________________________________________________________________________________
___________________________________________________________________________________
Interpreter/translator needed (including sign language)
J Yes J No
If yes, type needed:
_______________________________________________________________________________________________________________
___________________________________________________________________________________
If appellant not represented, has a list of legal referral and service organizations been provided.
Has a copy of this form been sent to all other parties?
J Yes J No
J Yes J No
PRIVACY ACT STATEMENT
The legal authority for the collection of information on this form is authorized by the Social Security Act (section 1155 of Title XI and sections
1852(g)(5), 1860D-4(h)(1), 1869(b)(1), and 1876 of Title XVIII). The information provided will be used to further document your appeal. The
Social Security Number will be used to verify the identity of the individual appellant. Submission of the information requested on this form is
voluntary, but failure to provide all or any part of the requested information may affect the determination of your appeal. Information you furnish
on this form may be disclosed by the Office of Medicare Hearings and Appeals to another person or governmental agency only with respect to
the Medicare Program and to comply with Federal laws requiring the disclosure of information or the exchange of information between the
Department of Health and Human Services and other agencies.
CMS-5011A/B U2 (08/05) EF (08/2005)
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