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R hearing J Part B determination issued by a Fiscal Intermediary (FI), Carrier, or Quality Improvement Organization (QIO) (Amount in controversy must be $100 or more.) Send copies of this completed form to: Original The FI, Carrier, or QIO that issued the Reconsideration/Fair Hearing Notice Copy Appellant Appellant (The party appealing the reconsideration determination) Beneficiary Provider or Supplier (Leave blank if same as the appellant.) Address (Leave blank if same as the app.

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