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Get Where Does The Form Hhs 727 Get Mailed

Rty seeking to appeal the CMS contractor s reconsideration determination or fair hearing decision.) Street City State Telephone Number ( Alternate Telephone Number ) ( FAX Number ( ZIP Code ) E-Mail ) Beneficiary Name (Leave blank if same as party name) Health Insurance Claim (HIC) Number Provider or Supplier (Leave blank if same as party name) I would like to request an extension to submit my request for an Administrative Law Judge (ALJ) hearing (forms CMS-5011A/B or CMS-20034.

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