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Get Form HHS-721 - U.S. Department Of Health And Human Services - Hhs

, the appellant, hereby give consent to to request and receive a copy of the following record(s) from the Office of Medicare Hearings and Appeals (OMHA), Department of Health and Human Services. Please specify below in detail the record(s) to which this consent applies. Include the title of the record and the date it was sent/created. If you need more room please attach another sheet of paper. Please check one: The third-party specified i.

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