DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
MEDICARE REDETERMINATION REQUEST FORM
1. Beneficiary's Name:___ 2. Medicare Number: ___ 3. Description of Item or Service in Question: ___ 4. Date the Service or Item was Received: ___ 5. I do not agree with the determination of my claim
You have been logged out of your account because someone has loged in to your account on a different computer. If you would like to continuie using PDFfiller please re-login. Pdffiller needs to inforce one user per account policy to insure account privacy and security.