DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
IDENTITY VERIFICATION
INSTRUCTIONS
If the Office of Medicare Hearings and Appeals (OMHA) has asked you to verify your identity, for instance, in
order to receive notification of whether the OMHA has any records in which you are identified, please complete
this form.
Name Date of Birth Social Security Number
Street Address
City
State ZIP Code
Phone Number
( )
E-Mail Address
VERIFYING YOUR IDENTITY
In order to verify your identity, you must have the statement below notarized by an official notary public.
I
Individual’s Name
Individual’s Signature Date
Notary Public’s Name
Notary Public’s Signature Date
NOTARY SEAL
Notary’s Expiration Date
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-733 (08/05)
PSC Publishing Services (301) 443-6740
EF
understand that the knowing and willful request for or acquisition of a record pertaining to an individual under false pretenses
is a criminal offense under the Privacy Act subject to a $5,000 fine.
, certify that I am in fact the individual I claim to be. I
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signature
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