DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST FOR SUBSTITUTION OF PARTY
UPON DEATH OF BENEFICIARY OR ENROLLEE
Instructions: If you have been informed that a beneficiary or enrollee who was a party to an appeal before an Administrative Law
Judge (ALJ) or attorney adjudicator with the Office of Medicare Hearings and Appeals (OMHA) has died, you may request to enter
the proceedings as a substitute party if you have a genuine financial interest in the deceased person's estate or claim and you have
legal authority to act on behalf of the deceased person. You may also request substitution if you are a provider or supplier who
furnished the item(s) or service(s) involved in the appeal and there is no other individual with a genuine financial interest.
Complete this form and send it to the assigned OMHA adjudicator (visit
www.hhs.gov/omha and use the appeal status lookup tool to
find your assigned adjudicator). If an adjudicator has not yet been assigned, send this form to OMHA Central Operations, Attention:
Substitution of Party Mail Stop (visit
www.hhs.gov/omha
or call the number at the bottom of this form for the full mailing address).
In addition, you must also submit evidence of the legal authority for you to act on behalf of the deceased person or, if you are the
provider or supplier who furnished the item(s) or services(s) involved in the appeal, evidence of the transactions that are the subject
of the claim(s) at issue.
Please note that if another party other than the deceased person filed a request for an ALJ hearing or review of a dismissal, the appeal
may still proceed, but the deceased person will no longer be a party to the appeal unless an eligible party is substituted. If the deceased
person was the only party that requested a hearing, the request for hearing will be dismissed unless an eligible party is substituted.
Section 1: What is the OMHA appeal number or the reconsideration (Medicare appeal or case) number?
OMHA Appeal Number (if known) Reconsideration Number (if OMHA appeal number not known)
Section 2: What is the information for the deceased beneficiary or enrollee?
Name (First, Middle initial, Last)
Date of Death
Section 3: What is the substitute party's information? (Representative information in next section)
Name (First, Middle initial, Last) Firm or Organization (if applicable)
Mailing Address
City State ZIP Code
Telephone Number Fax Number E-Mail
Section 4: What is the representative's information? Please attach an appointment of representation (form CMS-1696) or other
documents authorizing the representation. (Skip if you do not have a representative)
Name
Firm or Organization (if applicable)
Section 5: Indicate action you wish to take by checking one of the boxes below:
I do not wish to proceed with the appeal requested by the deceased person and I withdraw the request for hearing. (Include a
completed form OMHA-119)
I wish to proceed with the appeal, including any hearing that may be scheduled.
I wish to proceed with the appeal but am waiving an oral hearing before an ALJ and request that a decision be issued based on
the record. (Include a completed form OMHA-104)
Section 6: Sign and date this form:
Substitute Party 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-106 (03/17)
PAGE 1 OF 1
PSC Publishing Services (301) 443-6740.
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