Form revised 10/1/2019
Reconsideration Request Form
Directions: If you wish to appeal this decision, please fill out the required information below and mail this form to the
address shown below. At a minimum, you must complete/include information for items 1, 2a, 6, 7, and 11 but to help us
serve you better; please include a copy of the redetermination notice with your request.
Submit requests to:
C2C Innovative Solutions Inc.
QIC Part B South
P.O. Box 45300
Jacksonville, FL 32232-5300
1. Name of Beneficiary:______________________________________________________________________________
2a. Medicare ID:_______________________________________________________________________________
2b. Claim Number (ICN/DCN if available):________________________________________________________________
3. Provider Name:___________________________________________________________________________________
4. Person Appealing: Beneficiary Provider of Service Representative
5. Address of the Person Appealing:
City_________________________ Sta
te_______ ZIP Code____________
5a. Telephone Number of the Person Appealing:___________
5b. Email Address of the Person Appealing:________
6. Item or service you wish to appeal
Date of the
From_______________________ To________________________
8. Does this appeal involve an overpaym
ent? Yes No
Please include a copy of the demand letter with your request.
9. Why do you disagree? Or what are your reasons for appeal? (255 character limit; attach additional pages if necessary.)
10. You may also include any supporting materials to assist your appeal. Examples of supporting materials include:
Medical Records Office Records/Progress Notes Copy of the Claim
Treatment Plan Certification of Medical Necessity
11. Printed Name of Person Appealing:
Contractor Number
Redetermination Number