Form Cms-20031 - 2005 Transfer Of Appeal Rights
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1
2DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
TRANSFER OF APPEAL RIGHTS
Important: This form allows you to transfer your appeal rights to your health care provider for an item or
service. If your provider accepts your appeal rights, he or she cannot charge you for this item or service
(except for applicable coinsurance and deductible amounts) even if Medicare will not pay the claim. Please
see the back for more information before you complete this form.
Section I must be completed and signed by the beneficiary.
SECTION I: TRANSFER OF APPEAL RIGHTS
1. Name of Patient
(Please Print)
2. Medicare Number
4. Phone Number
(9 digits followed by an alpha/numeric suffix)
(Include area code)
3. Address
(Street)
City
State
ZIP
5. Item or Service
I, ___________________________________________________________, voluntarily transfer my
6.
appeal rights to __________________________________________________. I understand that I will
have no right to appeal a denied claim for this item or service unless I cancel the transfer in writing. I
also understand that I cannot be charged for this item or service (except for applicable coinsurance and
deductible amounts) unless I cancel the transfer.
7. Signature
Date
Section II must be completed and signed by the health care provider or supplier.
SECTION II: ACCEPTANCE OF APPEAL RIGHTS
I, _________________________________________________________________, accept the appeal
8.
rights for the item or service listed Line 5. I will not collect payment from the patient for this item or
service, except for any applicable deductible or coinsurance.
9. Signature
Date
11. Phone Number
10. Address
(Street)
City
State
ZIP
See the back of this form for more information.
Form CMS-20031 (05/05) EF 05/2005
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