Section 5: Do you intend to call any witnesses to provide testimony at the hearing?
No.
Yes, I intend to call the following witnesses (attach a continuation sheet if necessary):
Section 6: Do you object to any of the following conditions? (Check all that apply)
I object to the type of hearing scheduled. If you are an unrepresented beneficiary or enrollee, and a telephone hearing is
scheduled, you have the right to request that a VTC hearing be held instead if VTC technology is available. For all other parties,
if a telephone hearing is scheduled, the ALJ may find good cause for an appearance by VTC if he or she determines that VTC is
necessary to examine the facts or issues involved in the appeal.
If a telephone or VTC hearing is scheduled and the party, including an unrepresented beneficiary or enrollee, requests that an
in-person hearing be held instead, the ALJ, with the agreement of the Chief ALJ or designee, may find good cause for an
in-person hearing if VTC or telephone technology is not available, or if special or extraordinary circumstances exist.
I object to the type of hearing scheduled and request a (check one)
VTC or
in-person hearing because:
Note: No explanation is required if you are an unrepresented beneficiary or enrollee requesting a VTC hearing.
I object to the issues described in the notice of hearing. I understand that I must send a copy of my objection to the issues
to all the other parties who were sent a copy of the notice of hearing, and to CMS or a CMS contractor that elected to be a party
to the hearing (if you do not have these addresses, please contact the ALJ's adjudication team at the telephone number shown
in the letterhead of the notice of hearing). I understand that the ALJ will make a decision on my objection either in writing, at a
prehearing conference, or at the hearing.
I object to the issues described in the notice of hearing because:
I object to the ALJ assigned to my appeal. I understand that an ALJ cannot adjudicate an appeal if he or she is prejudiced or
partial with respect to any party or has an interest in the matter pending for decision, and that I may object to the ALJ assigned
to my appeal for these reasons. I understand that the ALJ will consider my objection and decide whether to proceed with the
appeal or withdraw. I understand that if I object to the ALJ assigned to my appeal, and the ALJ subsequently withdraws from the
appeal, another ALJ will be assigned, and any applicable adjudication time frame will be extended by 14 calendar days.
I object to the assigned ALJ because:
Section 7: If you are the appellant, do you want to waive or extend the time frame to decide your appeal? (If yes, check one)
I want to waive the time frame for the ALJ to decide my appeal. I understand that by waiving this time frame, the ALJ does
not have to decide my appeal within any applicable adjudication period that would otherwise apply.
I want to extend the time frame for the ALJ to decide my appeal. I want the time frame to be extended
calendar
days beyond any applicable adjudication period.
Section 8: Sign and date this form.
Party, Participant or Representative Signature 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(b)(1), and 1876 of Title XVIII). The information provided will be used to further document your appeal.
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.
If you need large print or assistance, please call 1-855-556-8475
OMHA-102 (08/17)
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