- Form #
- CMS 20034A/B
- Form Title
- REQUEST FOR MEDICARE HEARING BY AN ADMINISTRATIVE LAW JUDGE
- Revision Date
- O.M.B. #
- O.M.B. Expiration Date
- CMS Manual
- Special Instructions
- CMS-20034 A/B has been discontinued. See below for details.
The form “Request for Medicare Hearing by an Administrative Law Judge - CMS-20034 A/B” has been discontinued. It has been replaced by the form “Request for an Administrative Law Judge (ALJ) Hearing or Review of Dismissal - OMHA-100.” This change is effective January 2017.
The new form can be found on the Office of Medicare Hearings and Appeals (OMHA) website at:
The direct link to the new form “OMHA-100”:
In addition, the form OMHA 100A is used as an attachment to form OMHA 100 to identify multiple beneficiaries or enrollees associated with a single request for an Administrative Law Judge (ALJ) hearing or a review of dismissal. The direct link to form “OMHA-100A”: