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Get HHS OMHA-100 2017

Section 1: Which Medicare Part are you appealing (if known)? (Check one) Part A Part B Part C (Medicare Advantage) or Medicare Cost Plan Part D (Prescription Drug Plan) Section 2: Which party are you, or which party are you representing? (Check one) The Medicare beneficiary or enrollee, or a successor (such as an estate), who received or requested the items or services being appealed, or is appealing a Medicare Secondary Payer issue. The provider or supplier that furnished the items or servic.

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