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