Form Cms-3509 - Alj Medicare Case Folder (Cms)

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ALJ
MEDICARE CASE FOLDER
(CMS)
This file must be routed to the following address upon completion of OHA action:
Supervisor, ALJ Department
Empire Medicare Services
2651 Strang Boulevard
Yorktown Heights, New York 10598
If the original case file is separated for adjudication, please include a copy of this form
in each case file.
If you have any questions about this case file, please contact the originating contractor.
Contractor Name & Contractor Number
Address
Phone & Contact Name
This information MUST be completed by the originating contractor.
CMS-3509 (08-02)

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