DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB ExemptMEDICARE RECONSIDERATION REQUEST FORM — 2nd LEVEL OF APPEALBeneficiary’s name (First, Middle, Last) Medicare number Item or service you wish to appeal Date the service or item was received (mm/dd/yyyy)Date of the redetermination notice (mm/dd/yyyy) (please include a copy of the notice with this request) If you received your redetermination notice more than 180 days ago, include your reason for the late filing: Name of the Medicare contractor that made the redetermination (not required if copy of notice attached) Does this appeal involve an overpayment? (for providers and suppliers only) Yes NoI do not agree with the redetermination decision on my claim because: Additional information Medicare should consider:Do you have evidence to submit?I have evidence to submit. 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 reconsideration. I do not have evidence to submit.Person appealing: Beneficiary Provider/Supplier RepresentativeEmail of person appealing (optional) Name of person appealing (First, Middle, Last) Street address of person appealing CityStateZip codeTelephone number of person appealing (include area code) Date of appeal (mm/dd/yyyy) (optional) 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 & 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 83 Fed. Reg. 6591 (2/14/2018) or at https://www.hhs.gov/foia/privacy/sorns/cms-sorns.htmlForm CMS-20033 (01/20)Download and print to PDFNote: Download your information to PDF before printing.
