Get Form Hhs 725

This guide provides clear and concise instructions on how to fill out the Form Hhs 725 online, which is used to request a review of a dismissal issued by a qualified independent contractor. Follow these steps to ensure that your form is completed accurately and submitted correctly.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling in the appellant information. Provide the name of the party appealing the dismissal, along with their address, health insurance claim number, and contact information, including telephone and email.
3. Next, complete the beneficiary information section if the beneficiary's details differ from those of the appellant. Include their name, address, health insurance claim number, and contact details.
4. In the provider or supplier information section, complete this if the details differ from the appellant. Enter the necessary information such as name, address, and contact information.
5. Fill out the CMS contractor information by indicating the QIC that dismissed your case and the document control number assigned by the QIC. Include the dates of service from and to.
6. Express your request for an administrative law judge review in the designated area, and clearly explain why you disagree with the dismissal in the provided space.
7. Answer the questions regarding multiple claims or beneficiaries as applicable, and attach lists if necessary.
8. If you have a representative, complete their information and specify whether they are an attorney or non-attorney.
9. Indicate if you have additional evidence to submit and explain what you plan to provide if applicable.
10. Finally, provide your signature, name, and date at the bottom of the form. After completing the form, you can save your changes, download, print, or share the form as necessary.

Complete your documents online today to ensure your appeals are processed in a timely manner.