Beneficiarys name 2 Medicare number 3 Item or service you wish to appeal 4 Date the service or item was received 5 Date of the initial determination notice please include a copy of the notice with this request If you received your initial determ ID: 30502
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES OMB Exempt MEDICARE RE 1st LEVEL OF APPEAL Beneficiarys name Date of the initial determination notice Yes submit and when you intend to submit it. You may also submit additional evidence at a later Beneficiary Provider/Supplier 4 4 4 4 4 4 4