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Get Cgs Redetermination Form

RECONSIDERATION REQUEST FORM Redetermination Number Contractor 18003 CGS DME MAC - C DIRECTIONS If you wish to appeal this decision please fill out the required information below and mail this form to the address shown below. At a minimum you must complete/ include information for items 1 2a 6 7 11 12 but to help us serve you better please include a copy of the redetermination notice with your request. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5. Address of Person Appealing 6. Item or Service You Wish To Appeal 7. Date of Service From To 8. Does This Appeal Involve an Overpayment Yes No 9. Why Do You Disagree Or What Are Your Reasons For Your Appeal Attach additional pages if necessary. 10. Do You Have Any Supporting Material to Assist Your Appeal Example Medical Records Office Records/Progress Notes CMN 11. Printed Name of Person Appealing 12. Signature of Person Appealing DATE Revised February 11 2014. At a minimum you must complete/ include information for items 1 2a 6 7 11 12 but to help us serve you better please include a copy of the redetermination notice with your request. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5. Address of Person Appealing 6. Item or Service You Wish To Appeal 7. Date of Service From To 8. Does This Appeal Involve an Overpayment Yes No 9. Address of Person Appealing 6. Item or Service You Wish To Appeal 7. Date of Service From To 8. Does This Appeal Involve an Overpayment Yes No 9. Why Do You Disagree Or What Are Your Reasons For Your Appeal Attach additional pages if necessary. 10. Why Do You Disagree Or What Are Your Reasons For Your Appeal Attach additional pages if necessary. 10. Do You Have Any Supporting Material to Assist Your Appeal Example Medical Records Office Records/Progress Notes CMN 11. Do You Have Any Supporting Material to Assist Your Appeal Example Medical Records Office Records/Progress Notes CMN 11. Printed Name of Person Appealing 12. Signature of Person Appealing DATE Revised February 11 2014. At a minimum you must complete/ include information for items 1 2a 6 7 11 12 but to help us serve you better please include a copy of the redetermination notice with your request. C2C Solutions Inc* ATTN DME QIC PO Box 44013 Jacksonville Florida 32231-4013 1. Name of Beneficiary 2a* Medicare Number 2b. Claim Number ICN/DCN If Available 3. Provider Name 4. Person Appealing Beneficiary Provider of Service Representative 5.

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