hhs 723 form

DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of Medicare Hearings and Appeals WAIVER OF RIGHT TO AN ADMINISTRATIVE LAW JUDGE (ALJ) HEARING Name of Party Requesting the Waiver: Name Social Security Number Health Insurance Claim (HIC) Number ALJ Appeal Number Phone Number ( ) E-mail Although my right to a hearing before an ALJ has been explained to me, I do not want to participate in the hearing. I want to have my...
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hhs 723
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