Appeal Forms

General

Redetermination - (First level)

Reconsideration - (Second level)

  • CMS 20033 This link will take you to an external website. - Medicare Reconsideration Request

Administrative Law Judge (ALJ) Hearing - (Third level)

Medicare Appeals Council Review (Departmental Appeals Board (DAB)) - (Fourth level)

Form Assistance

PDF File Downloading Technical Assistance

Due to varying Internet Browsers and versions of Adobe, users may receive the error message, "Adobe PDF Document. There is a problem with Adobe Acrobat/Reader. If it is running, exit, and try again. (0:104)"

If this occurs, close the error message and use the browser "refresh" button, or press the F5 key, to reload the PDF.

If this error continues, it may be necessary to update your version of Adobe Reader, or to disable the option to display PDFs in your browser. See Display PDF in browser help webpage.

Interactive Form Tips

Select "Highlight fields" and/or "Highlight required fields" to ensure all form fields are completed.

To view field instructions (including CMS supplied instructions, when provided), hover over desired field.

Blank and completed forms may be saved to a user's computer. Right-click PDF hyperlink and select "Save as."

Electronic completion minimizes possibility of illegible handwritten forms.

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