Loading
Form preview picture

Get Cgs Redetermination Request Form

RECONSIDERATION REQUEST FORM Redetermination Number Contractor 18003 CGS DME MAC - C DIRECTIONS If you wish to appeal this decision please fill out the required information below and mail this form to the address shown below. At a minimum you must complete/ include information for items 1 2a 6 7 11 12 but to help us serve you better please include a copy of the redetermination notice with your request. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5. Address of Person Appealing 6. Item or Service You Wish To Appeal 7. Date of Service From To 8. Does This Appeal Involve an Overpayment Yes No 9. Why Do You Disagree Or What Are Your Reasons For Your Appeal Attach additional pages if necessary. 10. Do You Have Any Supporting Material to Assist Your Appeal Example Medical Records Office Records/Progress Notes CMN 11. Printed Name of Person Appealing 12. Signature of Person Appealing DATE Revised February 11 2014. At a minimum you must complete/ include information for items 1 2a 6 7 11 12 but to help us serve you better please include a copy of the redetermination notice with your request. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5. Address of Person Appealing 6. Item or Service You Wish To Appeal 7. Date of Service From To 8. Does This Appeal Involve an Overpayment Yes No 9. Address of Person Appealing 6. Item or Service You Wish To Appeal 7. Date of Service From To 8. Does This Appeal Involve an Overpayment Yes No 9. Why Do You Disagree Or What Are Your Reasons For Your Appeal Attach additional pages if necessary. 10. Why Do You Disagree Or What Are Your Reasons For Your Appeal Attach additional pages if necessary. 10. Do You Have Any Supporting Material to Assist Your Appeal Example Medical Records Office Records/Progress Notes CMN 11. Do You Have Any Supporting Material to Assist Your Appeal Example Medical Records Office Records/Progress Notes CMN 11. Printed Name of Person Appealing 12. Signature of Person Appealing DATE Revised February 11 2014. At a minimum you must complete/ include information for items 1 2a 6 7 11 12 but to help us serve you better please include a copy of the redetermination notice with your request. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5.

How It Works

C2C rating
4.8Satisfied
22 votes

Tips on how to fill out, edit and sign Administrators online

How to fill out and sign Revised online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Have you been looking for a fast and practical solution to complete Cgs Redetermination Request Form at a reasonable price? Our service provides you with a rich selection of forms that are offered for submitting online. It takes only a couple of minutes.

Follow these simple instructions to get Cgs Redetermination Request Form completely ready for sending:

  1. Get the sample you will need in our library of legal templates.
  2. Open the form in our online editor.
  3. Read the guidelines to discover which information you must provide.
  4. Click the fillable fields and put the required information.
  5. Add the date and insert your electronic autograph once you fill in all other boxes.
  6. Examine the form for misprints along with other mistakes. If there?s a need to correct some information, the online editor along with its wide variety of instruments are at your disposal.
  7. Download the new template to your computer by clicking on Done.
  8. Send the e-document to the parties involved.

Completing Cgs Redetermination Request Form does not need to be perplexing any longer. From now on easily cope with it from your apartment or at the business office right from your mobile device or personal computer.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

CGS FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to Cgs Redetermination Request Form

  • QIC
  • llc
  • C2C
  • CMN
  • overpayment
  • reconsideration
  • CGS
  • Attn
  • administrators
  • copyright
  • medicare
  • Revised
  • beneficiary
  • provider
  • solutions
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.