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Get HHS-730 2005-2024

I have fulfilled my duty to advise the appellant of the consequences of the withdrawal of the request for hearing and subsequent dismissal. Representative s Signature PRIVACY ACT STATEMENT The legal authority for the collection of information on this form is authorized by the Social Security Act section 1155 of Title XI and sections 1852 g 5 1860D-4 h 1 1869 h I and 1876 of Title XVIII. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Medicare Hearings and Appeals WITHDRAWAL OF REQUEST FOR AN ADMINISTRATIVE LAW JUDGE ALJ HEARING Appellant Name Street Address City State Telephone Number E-Mail ZIP Code Appellant s Representative if applicable Beneficiary Name leave blank if same as above Health Insurance Claim HIC Number Provider/Supplier Name leave blank if same as above ALJ Appeal Number I the appellant wish to withdraw my request for an Administrative Law Judge ALJ hearing before the Office of Medicare Hearings and Appeals OMHA that I filed on / / 20. I do not intend to further proceed with the appeal. I understand that by withdrawing my request for an ALJ hearing my appeal will be dismissed by the ALJ if no other party to the Center for Medicare and Medicaid Services CMS contractor s reconsideration determination or fair hearing decision has filed a valid Request for ALJ Hearing. I understand that the ALJ will not honor my request if the Notice of Decision has already been issued. I wish to withdraw my request for an ALJ hearing because Please use a separate sheet of paper if more room is needed. Appellant or representative Signature Date If the appellant s representative is completing this form the representative must read and sign the following statement I am legally authorized to represent the appellant. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Medicare Hearings and Appeals WITHDRAWAL OF REQUEST FOR AN ADMINISTRATIVE LAW JUDGE ALJ HEARING Appellant Name Street Address City State Telephone Number E-Mail ZIP Code Appellant s Representative if applicable Beneficiary Name leave blank if same as above Health Insurance Claim HIC Number Provider/Supplier Name leave blank if same as above ALJ Appeal Number I the appellant wish to withdraw my request for an Administrative Law Judge ALJ hearing before the Office of Medicare Hearings and Appeals OMHA that I filed on / / 20. I do not intend to further proceed with the appeal* I understand that by withdrawing my request for an ALJ hearing my appeal will be dismissed by the ALJ if no other party to the Center for Medicare and Medicaid Services CMS contractor s reconsideration determination or fair hearing decision has filed a valid Request for ALJ Hearing. I understand that the ALJ will not honor my request if the Notice of Decision has already been issued* I wish to withdraw my request for an ALJ hearing because Please use a separate sheet of paper if more room is needed* Appellant or representative Signature Date If the appellant s representative is completing this form the representative must read and sign the following statement I am legally authorized to represent the appellant. .

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