DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
WITHDRAWAL OF REQUEST FOR ADMINISTRATIVE LAW JUDGE (ALJ)
HEARING OR REVIEW OF DISMISSAL
Instructions: If you previously submitted a request for a hearing before an Administrative Law Judge (ALJ) or a request for review of
a dismissal, but have now changed your mind and do not wish to proceed with the appeal, you may withdraw your request if a
decision or other dispositive order has not yet been issued by an ALJ or attorney adjudicator.
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:
Withdrawal Mail Stop (visit
www.hhs.gov/omha
or call the number at the bottom of this form for the full mailing address).
Please note that even if you submit a withdrawal of a request for an ALJ hearing or a request for review of a dismissal, an appeal may
still proceed with respect to any other party who filed a valid request for hearing or request for review regarding the same claim(s) or
disputed matter.
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 party withdrawing the request for hearing or request for review? (Representative
information in next section)
Name (First, Middle initial, Last) Firm or Organization (if applicable)
Telephone Number
Section 3: What is the representative's information? (Skip if you do not have a representative)
Name
Firm or Organization (if applicable)
Telephone Number
Section 4: Please acknowledge the following by signing and dating this form:
I am the party that requested an ALJ hearing or requested review of the dismissal. I want to withdraw my request for hearing
or request for review, and do not intend to further proceed with my appeal. I understand that by submitting this withdrawal
request, my appeal will be dismissed by an ALJ or attorney adjudicator if no other party filed a valid request for hearing or
request for review of a dismissal for the same lower level decision or dismissal. I understand that if my appeal was already
assigned to an ALJ or attorney adjudicator, the ALJ or attorney adjudicator will not honor my withdrawal if a decision or other
dispositive order has already been issued.
I am legally authorized to represent the party that requested the ALJ hearing or requested review of the dismissal and have
fulfilled my duty to advise the party of the consequences of submitting this withdrawal and the subsequent dismissal.
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-119 (03/17)
PAGE 1 OF 1
PSC Publishing Services (301) 443-6740.
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