DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Medicare Hearings and Appeals FILING OF NEW EVIDENCE (For use when the Qualified Independent Contractor (QIC) issues the reconsideration determination.).
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How to fill out the Hhs 728 Form online
The Hhs 728 Form allows users to submit new evidence to the Office of Medicare Hearings and Appeals. This guide will provide a step-by-step approach to filling out the form online, ensuring you understand each section and field clearly.
Follow the steps to fill out the Hhs 728 Form online effectively.
- Click the ‘Get Form’ button to obtain the Hhs 728 Form and open it in the online editor.
- In the 'Party Information' section, provide the name of the person filing the evidence along with their contact details, including street address, city, state, ZIP code, and phone numbers.
- If the beneficiary name is different from the party name, fill in the 'Beneficiary Name' field. Otherwise, you may leave it blank.
- Enter the Health Insurance Claim (HIC) number, the name of the provider or supplier, and the Administrative Law Judge (ALJ) appeal number.
- In the 'Description of Evidence' section, describe the new evidence you wish to submit. Include the title, relevance, and date of creation. If applicable, add a 'good cause' statement explaining why this evidence was not submitted previously.
- Ensure you attach any additional evidence required and, if necessary, include a separate sheet of paper for more information.
- Sign the form in the 'Party Signature' section and enter the date of submission.
- Once you have filled out all the fields accurately, proceed to save your changes, download the completed form, print it, or share it as needed.
Begin filling out the Hhs 728 Form online today to ensure your evidence is submitted correctly.
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