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Request For Medicare Hearing By An Administrative Law Judge CMS-20034A-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 determinat ion issued by a Qualified Independent Contractor (QIC) oo Part B (Amount in controversy must be $100 or more.) S end copies of this completed form to: Original Office of Medicare Hearings and Appeals Field Office specified in the QIC Reconsideration Notice Copy Appellant Copy All other parties Failure to send a copy of this completed request to the other parties to the appeal will delay the start date of your appeal. Did you send all required copies? o Yes o No 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 QIC QIC that made the reconsideration 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: decision be made on the basis of the evidence in my Statement: If you have additional evidence to submit, please attach the evidence or attach case. (Complete form HHS-723, Waiver of Right to an a statement explaining what you intend to submit and when you intend to submit ALJ Hearing.) it. If you are a provider, supplier, or beneficiary represented by a provider or supplier, the evidence must be accompanied by a good cause statement explaining wh y the evidence is being submitted for the first time at the ALJlevel. 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? (If yes, a list of all the claims must be attached.) oYes oNo B) Does request involve multiple beneficiaries? (If yes, a list of beneficiaries, their HICNs and the dates of service. ) oYes oNo 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.) Must be completed by the provider/supplier if representing the beneficia ry: I waive my rights to charge and collect a fee for representing _________ _______________________________________before the Office of Medicare Hearings and Appeals. (Beneficiary name) Signature of provider/supplier representing beneficiary Date CMS-20034 A/B U3 (08/05) EF 08/2005 ATTACH A COPY OF THE RECONSIDERATION DETERMINATION (IF AVAILABLE) TO THIS COPY. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Must be completed by the provider/supplier if representing the beneficiar y, they furnished the item(s) or services(s) at issue, and the appeal involves a question of liability under section 1879(a)(2) of the Soc ial Security Act: I waive my right to collect payment from the beneficiary for the furnishe d items or services at issue involving 1879(a)(2) of the Social Secu rity Act.Signature of provider/supplier representing beneficiary Date 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 ALJ Hearing 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 Special 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 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.Submission of the information requested on this form is voluntary, but failure to provide all or any part of the requested information ma y affectthe determination of your appeal. Information you furnish on this form may be disclosed by the Office of Medicare Hearings and Appeals toanother person or governmental agency only with respect to the Medicare Program and to comply with Federal laws requiring the disclosure ofinformation or the exchange of information between the Department of Hea lth and Human Services and other agencies. CMS-20034 A/B U3 (08/05) EF 08/2005 American LegalNet, Inc. www.USCourtForms.com
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