Fillable OMHA-100A-Multiple-Claim-Attachment FORM OMHA-100A

Fill Online, Printable, Fillable, Blank OMHA-100A-Multiple-Claim-Attachment FORM OMHA-100A Form

Use Fill to complete blank online HEALTH AND HUMAN SERVICES (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

OMHA-100A-Multiple-Claim-Attachment FORM OMHA-100A

On average this form takes 41 minutes to complete

The OMHA-100A-Multiple-Claim-Attachment FORM OMHA-100A form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 165 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Health and Human Services

BROWSE HEALTH AND HUMAN SERVICES (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST FOR ADMINISTRATIVE LAW JUDGE (ALJ) HEARING OR
REVIEW OF DISMISSAL — MULTIPLE CLAIM ATTACHMENT
Provide the following information for each beneficiary or enrollee whose claim is being appealed from the Reconsideration or Dismissal.
Failure to specify a beneficiary or enrollee or date of service may result in the claim not being considered by the ALJ.
Beneficiary or
Enrollee Name
HICN
Beneficiary or Enrollee
Address, City, State, Zip
Date(s) of Service
Date Copy of
Request Sent*
Use additional sheets as necessary.
*See Section 10 of form OMHA-100 for information on this requirement. Indicate “n/a” if the
beneficiary or enrollee was not sent a copy of the Reconsideration or Dismissal.
If you need large print or assistance, please call 1-855-556-8475
OMHA-100A (01/17)
PSC Publishing Services (301) 443-6740.
EF
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

OMHA-100A-Multiple-Claim-Attachment FORM OMHA-100A

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document