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
I,
, the appellant, wish to withdraw my request for an Administrative Law
20
/
/
. 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)
EF
PSC Publishing Services (301) 443-6740