Part A Pre-Hearing Input Record {CMS-353} | Pdf Fpdf Doc Docx | Official Federal Forms

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Part A Pre-Hearing Input Record {CMS-353} | Pdf Fpdf Doc Docx | Official Federal Forms

Part A Pre-Hearing Input Record {CMS-353}

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

Alternate TextLast updated: 5/2/2006

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PAR T A PRE-HEARING INPUT RECORD RECORD IDENTIFIER H.I. CLAIM NUMBER ADMISSION/HHA DATE (MMDDYYYY) B                     SURNAME GIVEN NAME                  PROVIDER NUMBER REQUESTED BY HEARING FILED - (MMDDYYYY) BLANK - BENEFICIARY 1. ATTORNEY 3. PROVIDER        2. RELATIVE 4. OTHER         RECON. INTER. 5011 REC. DATE. - (MMDDYYYY)              DEV. REQ. DATE - (MMDDYYYY) REFERRED TO RO DATE - (MMDDYYYY)              RETURNED TO INT. DATE - (MMDDYYYY) DECISION MODIFIED 1. YES 2. NO          HEARING SENT OHA DATE - (MMDDYYYY) HEARING OFFICE            American LegalNet, Inc. www.USCourtForms.comForm CMS-353 (6-86)

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