Form Hhs 730 - Withdrawal Of Request For An Administrative Law Judge (Alj) Hearing

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of Medicare Hearings and Appeals

WITHDRAWAL OF REQUEST FOR AN

ADMINISTRATIVE LAW JUDGE (ALJ) HEARING

Appellant Name

Street Address

City

State

ZIP Code

Telephone Number

E-Mail

(

)

Appellant’s Representative (if applicable)

Street Address

City

State

ZIP Code

Telephone Number

E-Mail

(

)

Beneficiary Name (leave blank if same as above)

Health Insurance Claim (HIC) Number

Provider/Supplier Name (leave blank if same as above)

ALJ Appeal Number

, the appellant, wish to withdraw my request for an Administrative Law

. I

Judge (ALJ) hearing before the Office of Medicare Hearings and Appeals (OMHA) that I filed on

do not intend to further proceed with the appeal. I understand that by withdrawing my request for an ALJ hearing, my appeal will be

dismissed by the ALJ if no other party to the Center for Medicare and Medicaid Services (CMS) contractor’s reconsideration

determination or fair hearing decision has filed a valid Request for ALJ Hearing. I understand that the ALJ will not honor my request

if the Notice of Decision has already been issued. I wish to withdraw my request for an ALJ hearing because: (Please use a

separate sheet of paper if more room is needed.)

Appellant (or representative) Signature

Date

If the appellant’s representative is completing this form, the representative must read and sign the following statement:

I am legally authorized to represent the appellant. I have fulfilled my duty to advise the appellant of the consequences of the

withdrawal of the request for hearing and subsequent dismissal.

Representative’s Signature

Date

PRIVACY ACT STATEMENT

The legal authority for the collection of information on this form is authorized by the Social Security Act (section 1155 of Title XI and sections 1852(g)(5), 1860D-4(h)(1),

1869(h)(I), and 1876 of Title XVIII). The information provided will be used to further document your appeal. Submission of the information requested on this form is

voluntary, but failure to provide all or any part of the requested information may affect the determination of your appeal. Information you furnish on this form may be

disclosed by the Office of Medicare Hearings and Appeals to another person or governmental agency only with respect to the Medicare Program and to comply with

Federal laws requiring the disclosure of information or the exchange of information between the Department of Health and Human Services and other agencies.

HHS-730 (08/05)

PSC Publishing Services (301) 443-6740