MEDICARE RECONSIDERATION REQUEST FORM

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESMEDICARE RECONSIDERATION REQUEST FORM1. Beneficiary’s Name _________________________________________________________2. Medicare Number: _________________________________________________________3. Description of Item or Service in Question: ______________________________________4. Date the Service or Item was received: _________________________________________5. I do not agree with the determination of my claim. MY REASONS ARE:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. Date of the redetermination notice___________________________________________(If you received your redetermination more than 180 days ago, include your reason for not making thisrequest earlier.)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7. Additional Information Medicare should consider _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8. Requester’s Name __________________________________________________________9. Requester’s Relationship to the Beneficiary: _____________________________________10. Requester’s Address: _________________________________________________________________________________________________________________________________11. Requester’s Telephone Number: _____________________________________________12. Requester’s Signature: _____________________________________________________13. Date Signed: _____________________________________________________________14. I have evidence to submit. (Attach such evidence to this form.) I do not have evidence to submit.15. Name of the Medicare Contractor that Made the Redetermination ___________________NOTICE: Anyone who misrepresents or falsifies essential information requested by this form may upon conviction besubject to fine or imprisonment under Federal Law.Form CMS-20033 (05/05) EF (05/2005)H5434 21498 0406 PPO CMS Approval Date: 05/2006H1026 21498 0406 HMO CMS Approval Date: 05/2006

Instructions for submitting a Medicare Reconsideration request form:Members may return completed forms by fax or mail.Fax number: 1-585-425-5301Mailing Address:Maximus50 Square DriveSuite 120Victor, NY 14564