DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
Addendum to Settlement Conference Facilitation Confidentiality Agreement
Use this form if you require additional signature lines for the Settlement Conference Facilitation Confidentiality Agreement. Signatures
must be written in black or blue ink. OMHA cannot accept e-signatures at this time, except from persons with disabilities. Please scan
this form, along with your Settlement Conference Facilitation Confidentiality Agreement, into PDF format and e-mail it to
www.hhs.gov/omha
.
OMHA_SCFAppeals@cms.hhs.gov
.
This signature page is an addendum to the attached Settlement Conference Facilitation Confidentiality Agreement (Agreement). The
undersigned agree to the terms stated in the attached Agreement.
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OMHA (06/18)
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PSC Publishing Services (301) 443-6740.
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download the accessible version of this form the OMHA website at
If you have a disability that would prevent you from entering a handwritten signature, please
