DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
WAIVER OF ADVANCE WRITTEN NOTICE OF HEARING
Instructions: Written notice of an Administrative Law Judge (ALJ) hearing before the Office of Medicare Hearings and Appeals
(OMHA) is mailed, transmitted, or served at least 20 calendar days before the date of the hearing (or 3 calendar days before the date of
an expedited Part D hearing), unless the recipient agrees in writing to the notice being mailed, transmitted, or served fewer than 20
calendar days (or 3 calendar days) before the hearing. If you are a party or participant to an ALJ hearing, you may complete this form to
waive the advance written notice requirement and consent to receive notice fewer than 20 calendar days (or 3 calendar days) before
the hearing date.
Complete this form and send it to the assigned ALJ using the mailing address or fax number at the top of the notice of hearing. If an
adjudicator has not yet been assigned, mail this form to: OMHA Central Operations, Attention: Waiver Mail Stop, 200 Public Square,
Suite 1260, Cleveland, OH 44114-2316.
Section 1: What is the hearing information?
OMHA Appeal Number (if known) Reconsideration Number (if OMHA appeal number not known)
Appellant Name
Assigned ALJ (if known)
Section 2: What is your contact information?
Name (First, Middle Initial, Last) Firm or Organization (if applicable)
Mailing Address
City State ZIP Code
E-Mail Address Telephone Number Fax Number
Section 3: Acknowledge the following by signing and dating below:
•
I agree to waive the regulatory requirement that written notice of an ALJ hearing be mailed, transmitted, or served at least 20
calendar days (or 3 calendar days for an expedited Part D hearing) before the hearing date.
•
I understand that another hearing participant may choose not to waive its right to advance written notice of the ALJ hearing, in
which case the hearing would not be held until 20 calendar days (or 3 calendar days) after the notice of hearing is mailed,
transmitted, or served to that hearing participant.
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-143 (09/18) PAGE 1 OF 1
PSC Publishing Services (301) 443-6740.
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