Get Form Hhs 730. Withdrawal Of Request For An Administrative Law Judge (alj) Hearing - Hhs

Filling out the FORM HHS 730 is an important step for individuals wishing to withdraw their request for an Administrative Law Judge (ALJ) hearing. This guide will assist you in navigating each section of the form to ensure a smooth and efficient process.

Follow the steps to complete the withdrawal form accurately.

1. Press the ‘Get Form’ button to access the FORM HHS 730 and open it in the editor for completion.
2. Begin by entering your name in the 'Appellant Name' field. This is the individual who originally filed the request for the ALJ hearing.
3. Provide your street address, city, state, and telephone number in the designated fields to ensure proper identification.
4. If applicable, enter the Appellant’s Representative’s details, including their name, address, and contact information.
5. Fill in the Beneficiary Name, leaving this blank if it is the same as the appellant’s name. Additionally, provide the Health Insurance Claim (HIC) number and the Provider/Supplier Name if it is different from the appellant.
6. Input the ALJ Appeal Number related to your case to link your withdrawal request to the appropriate record.
7. In the designated section, express your intention to withdraw the request and include the date when the original request for an ALJ hearing was filed.
8. Specify your reasons for withdrawing the request. If you need additional space, you may attach a separate sheet of paper.
9. Include your signature and the date to validate the completion of the form. If a representative is signing on your behalf, they must also sign and date the form confirming their legal authority.
10. Review all fields to ensure accuracy before submitting the form. You can then save your changes, download, print, or share the completed document as needed.

Complete your FORM HHS 730 online for a seamless withdrawal experience.