DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST TO CORRECT, AMEND, OR DELETE A RECORD(S)
Records will only be corrected, amended, or deleted if the Office of Medicare Hearings and Appeals (OMHA) determines that the record is
not accurate, timely, complete, or relevant or necessary to accomplish an OMHA function based on a preponderance of the evidence. Only
the individual identified in the particular record may make such a request.
Please identify the record(s) in question. For each record, you must include: 1) the title; 2) date it was created/mailed; 3) whether you want
to correct, amend, or delete it; 4) how you want it corrected or amended, if applicable; and 5) why you want it corrected, amended or
deleted. If you need more room please attach another sheet of paper. Please attach any supporting evidence.
The records in question come from (please check one) :
Hard Copy Case File Medical/Vocational Expert File Medicare Appeals System (MAS)
If you are an Appellant, please provide the following information:
Name ALJ Appeal Number
Health Insurance Claim (HIC) Number Social Security Number Date of Birth
Phone Number
( )
E-mail
If you are a Medical or Vocational Expert, please provide the following information:
Name Profession
Specialty Social Security Number Date of Birth
Phone Number
( )
E-mail
The OMHA will either send you an acknowledgment of receipt of request or the decision with regard to your request within 10 working days
of receiving this request. If the OMHA approves your request, you will also be notified in writing of all prior disclosures of the record to other
individuals. All previous recipients of the record will be informed of the corrective action. If the OMHA denies your request, you have the
right to appeal. Your appeal must be in writing and be sent to:
Attn:
Assistant Secretary for Public Affairs
U.S. Department of Health and Human Services
200 Independence Ave., S.W.
Washington, D.C. 20201.
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-724 (08/05)
PSC Publishing Services (301) 443-6740
EF
