Appeals Forms - JA DME
- CMS-1696 - Appointment of Representative
- CMS 20031 - Transfer (Assignment) of Appeal Rights
- Documentation Checklists
Redetermination - (First level)
- CMS 20027 - Medicare Redetermination Request
- Medicare DME Redetermination Request [PDF]
Reconsideration - (Second level)
- CMS 20033 - Medicare Reconsideration Request
Administrative Law Judge (ALJ) Hearing - (Third level)
Medicare Appeals Council Review (Departmental Appeals Board (DAB)) - (Fourth level)
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.
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.
Last Updated Thu, 25 Oct 2018 12:52:21 +0000