DEPARTMENTOF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES TRANSFER OF APPEALRIGHTS Important: This form allows you to transfer your appeal rights to your health care provider for an item or service. If your provider accepts your appeal rights, he or she cannot c harge you for this item or service (except for applicable coinsurance and deductible amounts) even if Med icare will not pay the claim. Please see the back formore information before you complete this form. Section I must be completed and signed by the beneficiary. SECTION I: TRANSFER OF APPEALRIGHTS 1. Name of Patient (Please Print) 2. Medicare Number (9 digits followed by an alpha/numeric suffix) 4. Phone Number (Include area code) 3. Address (Street) City State ZIP 5. Item or Service 6.I, ___________________________________________________________, voluntar ily transfer my appeal rights to __________________________________________________. I u nderstand that I will have no right to appeal a denied claim for this item or service unless I cancel the transfer in writing. I also understand that I cannot be charged for this item or service (except for applicable coinsurance and deductible amounts) unless I cancel the transfer. 7. Signature Date Section II must be completed and signed by the health care provideror supplier. SECTION II: ACCEPTANCE OF APPEALRIGHTS 8.I, _________________________________________________________________, ac cept the appeal rights for the item or service listed Line 5. I will not collect payment from the patient for this item or service, except for any applicable deductible or coinsurance. 9. Signature Date 11. Phone Number 10. Address (Street) City State ZIP Form CMS-20031 (05/05) EF 05/2005 See the back of this form formore information. American LegalNet, Inc. www.USCourtForms.com>>>> 2 THIS INFORMATION MAY HELP ANSWER YOUR QUESTIONS ABOUT THIS FORM. 1. Why am I receiving this form? A provider or supplier may not have the right to appeal in some situations , so they may ask you to transfer your appeal rights to them. This allows them to appeal on their own to Medicare. 2. What are my appeal rights? You have the right to appeal if Medicare decides that they will not pay f or an item or service. Your appeal rights are your rights to ask Medicare to reconsider thei r decision to not pay for the item or service. 3. What does it mean to transfer my appeal rights? You have the right to transfer your appeal rights to your health care pro vider or supplier for an item or service. If Medicare decides not to pay for the item or service, your provider or supplier will be allowed to appeal the decision. You will not be able to appeal the decision; your provider must do it for you. 4. Who can I transfer my appeal rights to? You may transfer your appeal rights only to the individual who provided t he item or service that you listed in Section I of this form. 5. What financial risks do I take when I transfer my appeal rights? If a provider or supplier accepts your appeals rights, they cannot bill you for the item or service, unless you cancel the transfer or you already signed an Advance Beneficiary Notice. Whether or not you choose to transfer your appeal rights, you will be responsible for paying the appr opriate deductible or coinsurance amounts. 6. Am I transferring my appeal rights for all of my claims? No, you are only transferring your appeal rights for the item or service that you listed in Section I of this form. 7. How long does the transfer last? This transfer is permanent, unless you decide to cancel it. However, if you cancel the transfer, you may be responsible for payment if Medicare decides that they will not pa y for the item or service. 8. How can I cancel the transfer? You can cancel the transfer by indicating in writing that you no longer w ish to transfer your appeal rights for this item or service. You can do this at any time. For information about canceling the transfer, call 1-800-MEDICARE (1-800-633-4227). 9. Who can I contact if I need help completing this form? State Health Insurance Assistance Programs (SHIPs) are located in every State. These programs have volunteer counselors who can give you free assistance with Medicare questions. Please check your Medicare and You handbookto locate a program in your State. Or, for more information, visit www.medicare.gov. Form CMS-20031 (05/05) EF 05/2005 2 American LegalNet, Inc. www.USCourtForms.com