Appeal Of Determination

Download a blank fillable Appeal Of Determination in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Appeal Of Determination with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Form Approved
OMB No. 0960-0695
FOR OFFICIAL USE ONLY
Appeal of Determination for
Date received:
Extra Help with Medicare
Office code:
Request filed late:
Prescription Drug Plan Costs
1. Applicant’s Name:
2. Social Security Number:
3. Medicare Number (if different from Social Security number):
4. Spouse’s Name (if spouse lives at same address as you):
5. Spouse’s Social Security Number (if spouse lives at same address as you):
6. Spouse's Medicare Number (if different from spouse's Social Security number and spouse lives
at same address as you):
7. Please explain why you disagree with our decision:
8. Do you have additional information to support your appeal?
YES Send the additional information with this form to the address shown on the bottom
of page 2.
NO
9. Do you want a hearing? If you have a hearing, it will be by telephone.
YES You will receive a notice with the date and time of the hearing. Please complete
questions 10 through 13.
NO
You will receive a decision based on the information available and any additional
information you provide.
Form SSA-1021 (07-2014)
Page 1

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Ssa-1021-inst - Instructions For Completing The Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs Form Ssa-1021-inst - Instructions For Completing The Appeal Of Determination For Extra Help With Medicare Prescription Drug Plan Costs Legal
Application For Appeal Of The Disability Rent Increase Exemption Determination Form Application For Appeal Of The Disability Rent Increase Exemption Determination Form Legal
Determination Form - New York Division Of Tax Appeals Determination Form - New York Division Of Tax Appeals Financial
Determination Form - New York Division Of Tax Appeals Determination Form - New York Division Of Tax Appeals Financial
Determination Form - New York Division Of Tax Appeals Determination Form - New York Division Of Tax Appeals Financial
Notice Of Exception To Administrative Law Judge's Determination Form - State Of New York Tax Appeals Tribunal Notice Of Exception To Administrative Law Judge's Determination Form - State Of New York Tax Appeals Tribunal Legal
Petiton To Review Final Determination Of The Commissioner Of Finance - New York City Tax Appeals Tribunal Petiton To Review Final Determination Of The Commissioner Of Finance - New York City Tax Appeals Tribunal Financial
Small Claims Determination Form - New York Division Of Tax Appeals Small Claims Determination Form - New York Division Of Tax Appeals Financial
Small Claims Determination Form - New York Division Of Tax Appeals Small Claims Determination Form - New York Division Of Tax Appeals Financial
Appeal Of Denial Of A Senior Or Veteran Exemption Form Appeal Of Denial Of A Senior Or Veteran Exemption Form Legal

Related Categories

Parent category: Medical
Download
Go
Page of 4