DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST FOR COPY OF RECORD(S):
THIRD-PARTY WITH THE INDIVIDUAL APPELLANT'S CONSENT
This form is only applicable to third-parties with consent from the individual appellant.
I,
, am requesting a copy of the following record(s) from
the Office of Medicare Hearings and Appeals, Department of Health and Human Services. I have received written consent from
the appellant to have copies of the appellant's record(s).
Please check if applicable:
I am requesting a copy of the entire record I am requesting a partial copy of the record
NOTE:
If you are not requesting a copy of the entire record, please specify below in detail the record(s) you are requesting. Include the
title of the record and the date it was sent/created. If you need more room please attach another sheet of paper.
Please provide the information for the appellant if available:
Name ALJ Appeal Number
Health Insurance Claim (HIC) Number Social Security Number Date of Birth
Please check if applicable: I have already received a copy of the record(s) I am requesting.
The requested record(s) will be sent to the following address:
Street City
State ZIP Code Third-Party's Phone Number
APPELLANT CONSENT
Please attach the individual appellant's original written consent that authorizes you to have copies of the individual appellant's record(s). You should use the
form entitled “Individual Appellant's Consent to Third-Party for Copies of the Individual Appellant's Record(s)," HHS-721, to satisfy these requirements. The
consent must be signed and dated by both you and the individual appellant and must specify whether you have access to the entire record or only a portion.
If you are only authorized to have access to a portion, the consent must specify which record(s). The consent must also specify whether any information is
to be redacted, for instance the appellant's Social Security or Medicare number. You must get the written consent notarized by an official notary public.
HOW TO CALCULATE FEES
You may be charged a fee for photocopying. Copying of records susceptible to photocopying is assessed at 10 cents per page and copying of records not
susceptible to photocopying is assessed at actual cost. No charge will be made if the total amount of copying does not exceed $25. If the total cost exceeds
$25, the requesting party will be charged in full. The Office of Medicare Hearings and Appeals (OMHA) will send you an invoice to the address you have
listed in this form unless otherwise specified if we determine that you will be charged a fee for photocopying. The OMHA will send the requested copies
when we have received payment for the fee.
The OMHA will make every effort to deliver a copy of the requested records before the date of the hearing.
PRIVACY ACT STATEMENT
The legal authority for the collection of information on this form is authorized by the Social Security Act (section 1155 of Title XI and sections 1852(g)
(5), 1860D-4(h)(1), 1869(h)(I), and 1876 of Title XVIII). The information provided will be used to further document your appeal. The Social Security
Number will be used to verify the identity of the individual appellant. 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 Office of Medicare Hearings and Appeals to another person or governmental agency only with respect to the Medicare Program and to comply
with Federal laws requiring the disclosure of information or the exchange of information between the Department of Health and Human Services and
other agencies.
HHS-720 (08/05)
PSC Publishing Services (301) 443-6740
EF
