Office of Medicare Hearings and Appeals (OMHA)

Forms Needed for Your Level 3 Your Appeal

Below is a list of Level 3 forms only that may pertain to your request for a hearing by an Administrative Law Judge.

Request or Waive an Administrative Law Judge Hearing with OMHA
Pre-Hearing Forms Needed by OMHA
Records, Record Change, and Information Requests
Request for Substitution Upon Death of Beneficiary

Request or Waive an Administrative Law Judge Hearing with OMHA

Form	Description
Requests for Medicare Hearing by an Administrative Law Judge (ALJ) (For a reconsideration/fair hearing determination issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO) Form CMS 5011 A/B [PDF - 88KB]	This form is used to request an Administrative Law Judge (ALJ) review of a reconsideration/fair hearing determination issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO). Remember, the remaining amount in controversy must meet the current minimum for an ALJ review.
Requests for Medicare Hearing by an Administrative Law Judge (ALJ) (For a reconsideration determination issued by a Qualified Independent Contractor (QIC)) Form CMS 20034 A/B [PDF - 85KB]	This form is used to request an Administrative Law Judge (ALJ) review of a reconsideration determination issued by a Qualified Independent Contractor (QIC). Remember, the remaining amount in controversy must meet the current minimum for an ALJ review.
Request for Administrative Law Judge (ALJ) to Review Dismissal by the Qualified Independent Contractor Form HHS-725 [PDF - 36KB]	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.
Extension Request to File a Request for an Administrative Law Judge Hearing Form HHS 727 [PDF - 26KB]	This form is used to request an extension to submit your request for an Administrative Law Judge (ALJ) hearing with the Office of Medicare Hearings and Appeals (OMHA) beyond the normal 60 calendar days. The ALJ has the discretion to accept or deny your request based on your good cause explanation as to why you are unable to submit your request within the 60 days.
Withdrawal of Request for an Administrative Law Judge (ALJ) Hearing Form HHS-730 [PDF - 36KB]	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.
Waiver of Right to An Administrative Law Judge (ALJ) Hearing Form HHS-723 [PDF - 36KB]	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.
Withdrawal of Waiver of Right to an Administrative Law Judge (ALJ) Hearing Form HHS-731 [PDF - 36KB]	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 time frame beyond the normal period in order to schedule and hold the hearing.

Pre-Hearing Forms Needed by OMHA

Form	Description
Response to Notice of Hearing Form HHS-729 [PDF - 36KB]	This form is used to begin the Level 3 appeals. You need to review items 1 through 5 and respond appropriately. The form must be returned to the Office of Medicare Hearings and Appeals within five (5) days of receipt.
Identity Verification Form HHS-733 [PDF - 36KB]	This form is used by the Office of Medicare Hearings and Appeals when it needs to confirm your identity.
Filing of New Evidence Form HHS-728 [PDF - 36KB]	This form is used to submit additional evidence to the Administrative Law Judge (ALJ).
Appointment of Representative Form CMS-1696 [PDF - 36KB]	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.

Records, Record Change, and Information Requests

Form	Description
Request for Copy of the Record(s) in the Case File Form HHS-719 [PDF - 36KB]	This form is used by you or your authorized or appointed representative to request a copy of all or part of your record.
Request for Copy of the Record(s): Third-Party with the Individual Appellant's Consent Form HHS-720 [PDF - 36KB]	This form is used by a third party to request, with your consent, a copy of all or part of your record.
Individual Appellant's Consent to Third-Party for Copies of the Individual Appellant's Record(s) Form HHS-721 [PDF - 36KB]	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.
Request to Correct, Amend, or Delete a Record(s) Form HHS-724 [PDF - 36KB]	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.
Payment Information Report Form HHS-734 [PDF - 36KB]	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 payment of Medicare services.

Request for Substitution Upon Death of Beneficiary

Form

Description

Request for Substitution of Party Upon the Death of Beneficiary

Form HHS-722 [PDF - 36KB]

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.