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Medicare Appeals Forms
You can view and print appeal forms online by accessing the links below. All of the forms are Adobe Acrobat version 5.0 accessible or in text only format. You will need Adobe Reader software to view the files.
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People with visual disabilities can download tools and information at http://access.adobe.com to help make Adobe PDF files accessible.
Please note the time limits for requesting a Part A reconsideration and a Part B review have changed for all claims with initial determinations made on or after 10/1/2002. The forms, located below, for requesting a reconsideration and a review have not yet been revised due to the paperwork reduction act process. Therefore, these forms still reflect the old filing time limits. The new time limits allow people 120 days in which to request a reconsideration or a review. The new forms will be posted as soon as they are available.
See Chart Below
Medicare Appeals Forms |
Form Number |
Form Information |
CMS-1696 |
Appointment of Representative
View Form in Adobe PDF (Size: 10 KB) |
CMS-1965 |
Request for Hearing - Part B Medicare Claim
View Form in Adobe PDF (Size: 9 KB) |
CMS-20034A/B, CMS-5011A/B |
Beginning on July 1st, please follow the instructions below when filing your Request for Medicare Hearing before an Administrative Law Judge (ALJ).
If your reconsideration determination was issued by a Qualified Independent Contractor (QIC) please use form CMS-20034A/B
View Form in Adobe PDF (Size: 38 KB).
If your reconsideration or fair hearing determination was issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO) please use form CMS-5011A/B
View Form in Adobe PDF (Size: 41 KB).
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CMS-10003-NDMC |
Notice of Denial of Medical Coverage for Medicare Health Plans
View Form in Adobe PDF (Size: 31 KB)
View Instructions in Adobe PDF (Size: 22 KB) |
CMS-10003-NDP |
Notice of Denial of Payment for Medicare + Choice Plans
View Form in Adobe PDF (Size: 24.84 KB)
View Instructions in Adobe PDF (Size: 13.82 KB) |
CMS-10095 (DENC) |
Detailed Explaination of Non-coverage
View Form in Adobe PDF (Size: 12.64 KB)
View Instructions in Adobe PDF (Size: 16.72 KB) |
CMS-20027 |
Medicare Redetermination Request Form
View Form in Adobe PDF (Size: 27 KB) |
CMS-20031 |
Transfer (Assignment) Of Appeal Rights
View Form in Adobe PDF (Size: 40 KB) |
CMS-20033 |
Medicare Reconsideration Request Form
View Form in Adobe PDF (Size: 27 KB) |
All CMS forms can be found at http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp.
Medicare Appeals and Grievances Information
Page Last Updated: August 11, 2008
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