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Request For Medicare Hearing By An Administrative Law Judge CMS-5011A-B - Official Federal Forms
| Request For Medicare Hearing By An Administrative Law Judge Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENTOF HEALTH AND HUMAN SERVICES OFFICE OF MEDICARE HEARINGS AND APPEALS REQUEST FOR MEDICARE HEARING BYAN ADMINISTRATIVE LAW JUDGE oo Part A Effective July 1, 2005. For use by party to a reconsideration/fair heari ng determination issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO) oo Part B (Amount in controversy must be $100 or more.) S end 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 (Leave blank if same as the appellant.) Provider or Supplier (Leave blank if same as the appellant.) Address Address City State Zip Code City State Zip Code Area Code/Telephone Number E-mail Address Area Code/Telephone Number E-mail Address Health Insurance (Medicare) Claim Number Document control number assigned by the FI, Carrier, or QIO FI, Carrier, or QIO that made the reconsideration/fair hearing determination Dates of Service From To I DISAGREE WITH THE DETERMINATION MADE ON MYAPPEALBECAUSE: ________________________________________________________________________ ____________________________________________ ________________________________________________________________________ ____________________________________________ You have a right to be represented at the hearing. If you are not represe nted 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 oI wishto have a hearing. Check oI haveadditional evidence to submit. Only One Only One oI do not wishto have a hearing and I request that a oI have no additional evidence to submit. Statement: Statement: decision be made on the basis of the evidence in my case. (Complete form HHS-723, Waiver of Right to an ALJHearing.) 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 r epresentative at the hearing. o Yes o No 1. (Appellants Signature) Date 2. (Representatives Signature/Name) Date Address Address oAttorney oNon-Attorney City State Zip Code City State Zip Code Area Code/Telephone Number E-mail Address Area Code/Telephone Number E-mail Address Answer the following questions that apply: A) Does request involve multiple claims? oYes oNo (If yes, a list of all the claims must be attached.) B) Does request involve multiple beneficiaries? oYes oNo (If yes, a list of beneficiaries, their HICNs and the dates of the appl icable reconsideration determinations must be attached.) C) Did the beneficiary assign his or her appeal rights to you as the provid er/supplier? oYes oNo (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 pursua nt to 1842(I)(1)(A) of the Social Security Act? oYes oNo CMS-5011A/B U2 (08/05) EF 08/2005ATTACH A COPYOF THE RECONSIDERATION/FAIR HEARING DETERMINATION American LegalNet, Inc. (IF AVAILABLE) TO THIS COPY. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 TO BE COMPLETED BYTHE OFFICE OF MEDICARE HEARINGS AND APPEALS Is this request filed timely? oYes oNo If no, attach appellants explanation for delay. If there is no explanation, send a Notice of Late Filing of Request fo r ALJHearing to the appellant and representative, if applicable, to request such an explanat ion. Request received on Field Office Employee Assigned on Assigned by Assigned to S pecial response case? oYes oNo If yes, explain why and state the targeted adjudication deadline. ________________________________________________________________________ _______________________________________ ________________________________________________________________________ ___________ Interpreter/translator needed (including sign language) o Yes o No If yes, type needed: ________________________________________________________________________ _______________________________________ ________________________________________________________________________ ___________ If appellant not represented, has a list of legal referral and service organizations been provided. o Yes o No Has a copy of this form been sent to all other parties? o Yes o No PRIVACY ACT STATEMENT The legal authority for the collection of information on this form is au thorized by the Social Security Act (section 1155 of Title XI and sections1852(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. TheSocial Security Number will be used to verify the identity of the indivi dual appellant. Submission of the information requested on this form isvoluntary, but failure to provide all or any part of the requested information ma y affect the determination of your appeal. Information you furnishon this form may be disclosed by the Office of Medicare Hearings and Appeals to another person or governmental agency only with respect tothe Medicare Program and to comply with Federal laws requiring the discl osure of information or the exchange of information between theDepartment of Health and Human Services and other agencies. CMS-5011A/B U2 (08/05) EF (08/2005) American LegalNet, Inc. www.USCourtForms.com
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