ALJ Medicare Case Folder (CMS) {CMS-3509} | Pdf Fpdf Doc Docx | Official Federal Forms

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ALJ Medicare Case Folder (CMS) {CMS-3509} | Pdf Fpdf Doc Docx | Official Federal Forms

ALJ Medicare Case Folder (CMS) {CMS-3509}

This is a Official Federal Forms form that can be used for Centers For Medicare And Medicaid Services.

Alternate TextLast updated: 11/8/2010

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Description

ALJ MEDICARE CASE FOLDER (CMS) This file must be routed to the following address upon completion of OHA action: Supervisor, ALJ Department Empire Medicare Services 2651 Strang Boulevard Yorktown Heights, New York 10598 If the original case file is separated for adjudication, please include a copy of this form in each case file. If you have any questions about this case file, please contact the originating contractor. Contractor Name & Contractor Number Address Phone & Contact Name This information MUST be completed by the originating contractor. CMS-3509 (08-02) American LegalNet, Inc. www.USCourtForms.com

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