dd 553
Provider Dispute/Appeal Form
Jan 1, 2020 Please attach all pertinent documentation to this form. Additional submission methods: Fax: (877) 553-6504. E-mail: MFLProviderAppeals
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Financial Disclosure Statement (PDF, 2 pages, 553 KB). A borrower should submit this form to request a temporary payment reduction due to financial difficulty.
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Part 553 - Forms
This subpart lists standard and GSA forms prescribed or referenced in Parts 501551 and 571. (b) This subpart does not list standard forms listed in the FAR.
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