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Omha-addendum-to-settlement-508-06-13-2018 FORM OMHA Addendum_508

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
Addendum to Settlement Conference Facilitation Confidentiality Agreement
NOTE: This is an accessible version of this form, to be completed only by individuals with a disability that would prevent the individual
from entering a handwritten signature. All other individuals should use the version of this addendum that requires a handwritten signature,
available on the OMHA website at
www.hhs.gov/omha
.
Use this form if you require additional signature lines for the Settlement Conference Facilitation Confidentiality Agreement. Please send
this form, along with your Settlement Conference Facilitation Confidentiality Agreement, as PDF attachments and e-mail them to
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)
PAGE 1 OF 1
PSC Publishing Services (301) 443-6740.
EF
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Completed 16 February 2020

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