Form [PDF]
| Form Title | Description |
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HHS-719 | Request for Copy of the Record(s) in the Case File | This form is for use by you or your authorized or appointed representative to request a copy of all or part of your record. |
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HHS-720 | Request for Copy of the Record(s): Third-Party with the Individual Appellant's Consent | This form is used by a third party to request, with your consent, a copy of all or part of your record. |
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HHS-721 | Individual Appellant's Consent to Third-Party for Copies of the Individual Appellant's Record(s) | This form is used by you to consent to a request by a third party to receive a copy of all or part of your record. |
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HHS-722 | Request for Substitution of Party Upon the Death of Beneficiary | This form allows a substitution if the Medicare beneficiary died after a hearing was requested but before the hearing was held. The substitute party can be either someone with legal authority to act on behalf of the beneficiary or, if no such individual exists with a genuine financial interest, it can be the provider or supplier who furnished items or services. |
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HHS-723 | Waiver of Right to An Administrative Law Judge (ALJ) Hearing | This form is used to waive your right to have an oral hearing before the Administrative Law Judge (ALJ). If you submit this form, your case will be decided on the record without an oral hearing. |
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HHS-724 | Request to Correct, Amend, or Delete a Record(s) | This form is used to request a correction, amendment, or deletion of a record. After you submit this form, it is up to the Administrative Law Judge (ALJ) to determine whether the record should be corrected, amended, or deleted. |
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HHS-725 | Request for Administrative Law Judge (ALJ) to Review Dismissal by the Qualified Independent Contractor | This form is used to request an Administrative Law Judge (ALJ) review of a dismissal of your request for an appeal. Remember, the remaining amount in controversy must meet the current minimum for an ALJ review. |
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HHS-727 | Extension Request to File a Request for an Administrative Law Judge (ALJ) Hearing | Normally, you need to request an Administrative Law Judge (ALJ) hearing within 60 days of your reconsideration. This form is used to request an extension to the 60-day deadline. You should understand that the ALJ will assess your reasons for an extension and grant or deny your request. |
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HHS-728 | Filing of New Evidence | This form is used to submit additional evidence to the Administrative Law Judge (ALJ). |
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HHS-729 | Response to Notice of Hearing | This form is used to begin the Level 3 appeals. You need to review items 1 to 5 and respond appropriately. The form must be returned to the Office of Medicare Hearings and Appeals within five (5) days of receipt. |
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HHS-730 | Withdrawal of Request for an Administrative Law Judge (ALJ) Hearing | This form is used to withdraw your request for an Administrative Law Judge (ALJ) hearing before the Office of Medicare Hearings and Appeals (OMHA). If you file this form, your appeal will be dismissed by the ALJ if no other party has filed a valid Request for ALJ Hearing. Your request will not be honored if the ALJ has already issued a decision. |
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HHS-731 | Withdrawal of Waiver of Right to an Administrative Law Judge (ALJ Hearing | This form is used to withdraw your prior decision to waive your right to have a hearing before the Administrative Law Judge (ALJ). Your request will be honored only if the ALJ has not yet issued a decision. The ALJ may extend the decision-making timeframe beyond the normal period in order to schedule and hold the hearing. |
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HHS-733 | Identity Verification | This form is used by the Office of Medicare Hearings and Appeals when it needs to confirm your identity. |
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HHS-734 | Payment Information Report | This form is used by the Office of Medicare Hearings and Appeals to collect your bank information in order to make the direct deposit into your account. This is not for payment of Medicare services. |
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CMS-1696 | Appointment of Representative | This form is used to appoint a representative to assist with an appeal. An appointed representative may be a family member, friend, lawyer or provider/supplier. |
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CMS-20034 | Request for Medicare Hearing by an Administrative Law Judge | This form is used to request a Medicare Hearing by an Administrative Law Judge (ALJ). It is intended for use by those who have received a reconsideration determination issued by a Qualified Independent Contractor (QIC). |
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