Form OMHA-100A Request for Administrative Law Judge (Alj) Hearing or Review of Dismissal - Multiple Claim Attachment

Form OMHA-100A or the "Request For Administrative Law Judge (alj) Hearing Or Review Of Dismissal '- Multiple Claim Attachment" is a form issued by the U.S. Department of Health and Human Services.

Download a PDF version of the Form OMHA-100A down below or find it on the U.S. Department of Health and Human Services Forms website.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST FOR ADMINISTRATIVE LAW JUDGE (ALJ) HEARING OR
REVIEW OF DISMISSAL — MULTIPLE CLAIM ATTACHMENT
Provide the following information for each beneficiary or enrollee whose claim is being appealed from the Reconsideration or Dismissal.
Failure to specify a beneficiary or enrollee or date of service may result in the claim not being considered by the ALJ.
Beneficiary or
Beneficiary or Enrollee
Date Copy of
HICN
Date(s) of Service
Enrollee Name
Address, City, State, Zip
Request Sent*
Use additional sheets as necessary.
*See Section 10 of form OMHA-100 for information on this requirement. Indicate “n/a” if the
beneficiary or enrollee was not sent a copy of the Reconsideration or Dismissal.
If you need large print or assistance, please call 1-855-556-8475
OMHA-100A (01/17)
PSC Publishing Services (301) 443-6740.
EF
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Medicare Hearings and Appeals
REQUEST FOR ADMINISTRATIVE LAW JUDGE (ALJ) HEARING OR
REVIEW OF DISMISSAL — MULTIPLE CLAIM ATTACHMENT
Provide the following information for each beneficiary or enrollee whose claim is being appealed from the Reconsideration or Dismissal.
Failure to specify a beneficiary or enrollee or date of service may result in the claim not being considered by the ALJ.
Beneficiary or
Beneficiary or Enrollee
Date Copy of
HICN
Date(s) of Service
Enrollee Name
Address, City, State, Zip
Request Sent*
Use additional sheets as necessary.
*See Section 10 of form OMHA-100 for information on this requirement. Indicate “n/a” if the
beneficiary or enrollee was not sent a copy of the Reconsideration or Dismissal.
If you need large print or assistance, please call 1-855-556-8475
OMHA-100A (01/17)
PSC Publishing Services (301) 443-6740.
EF

Download Form OMHA-100A Request for Administrative Law Judge (Alj) Hearing or Review of Dismissal - Multiple Claim Attachment

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