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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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.

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).
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