2. 1. Beneficiary's Name
4. 2. Medicare Number
6. 3. Item or service you wish to appeal:
8. 4. Date the service or item was received:
   4. Date the service or item was received:
10. 5. Date of Initial Determination Notice
    5. Date of Initial Determination Notice
12. If you received your initial determination notice more than 120 days ago, include your reason for the late filing.
14. Include a copy of the notice with this request:
16. 5a. Name of Medicare contractor that made the determination (not required):
18. 5b. Does this appeal involve an overpayment?

    1. Yes
    2. No

    For providers and suppliers only.
20. 6. I do not agree with the determination decision on my claim because:
22. 7. Additional information Medicare should consider:
24. 8. Evidence

    1. I have evidence to submit.
    2. I do not have evidence to submit.
25. 8a.
    Please attach the evidence to this form or attach a statement explaining what you intend to submit and when you intend to submit it. You may also submit additional evidence at a later time, but all evidence must be received prior to the issuance of the redetermination.
27. 9. Person appealing:

    1. Beneficiary
    2. Provider / Supplier
    3. Representative
29. 10. Name of Person Appealing
31. 10a. Address
33. City
34. State
35. Zip Code
37. 10b. Phone
39. 11. eSignature of Person Appealing
40. 11. Date
    11. Date
42. Privacy Act Statement
    The legal authority for the collection of information on this form is authorized by section 1869 (a)(3) of the Social Security Act. The information provided will be used to further document your appeal. Submission of the information requested on this form is voluntary, but failure to provide all or any part of the requested information may affect the determination of your appeal. Information you furnish on this form may be disclosed by the Centers for Medicare and Medicaid Services to another person or government agency only with respect to the Medicare Program and to comply with Federal laws requiring or permitting the disclosure of information or the exchange of information between the Department of Health and Human Services and other agencies. Additional information about these disclosures can be found in the system of records notice for system no. 09-70-0566, as amended, available at 71 Federal Regulation 54489 (2006)
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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field