Health Law Forms

• Health Information Privacy Complaint
• Filing A Claim For Your Health Or Disability Benefits
• COBRA Fact Sheet
• HIPAA Fact Sheet
• Your Health Plan and HIPAA...Making The Law Work For You
• Patient's Request for Medical Payment (Medicare)
  This form is used by the beneficiary to file a claim with Medicare for services and/or supplies received.
• Appointment of Representative (for Medicare Claims)
  Use this form if you want to name someone to represent you to help appeal your Medicare claim.
• Transfer of Appeal Rights (Medicare)
  This form allows you to transfer your appeal rights to your health care provider for an item or service. If your provider accepts your appeal rights, he or she cannot charge you for this item or service (except for applicable coinsurance and deductible amounts) even if Medicare will not pay the claim.
• Medicare Redetermination Request Form
  If you don't agree with the initial claim decision by Medicare, you should use this form to appeal your claim. This is called a redetermination and is the first level of the appeals process. This is done by the Medicare Contractor who processed your claim. Any dollar amount can be appealed at this level, but it needs to be submitted within 120 days from the date you received the initial claim decision. This is normally the date shown on your Medicare Summary Notice (MSN). To file an appeal, you can also follow the instructions on your MSN by signing and returning the notice to the Medicare Contractor who processed your claim.
• Medicare Reconsideration Request Form
  Use this form if you are dissatisfied with the redetermination decision made during your first level of appeal. This form is used for the second level of appeals for your claim. This request is called a reconsideration and is done by a Qualified Independent Contractor (QIC). Any dollar amount can be appealed at this level, but it needs to be submitted within 180 days from the date of your redetermination decision.