FORM OMHA-100. Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal - hhs 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1, selecting the Medicare Part you are appealing by checking the appropriate box.
3. In Section 2, indicate your party status by checking the relevant option—whether you are a beneficiary, provider, or other representative.
4. Fill out your information in Section 3, including your name, address, and contact details. Ensure accuracy for correspondence.
5. If applicable, complete Section 4 with your representative's information. If you do not have a representative, skip this section.
6. In Section 5, provide details about what is being appealed. Attach any necessary documents as indicated.
7. For prescription drug appeals only, complete Section 6 regarding the specific drugs and expedited hearing requests.
8. Use Sections 7 through 10 to explain your disagreement with the dismissal and provide any evidence if available.
9. Finally, follow the filing instructions in Section 11 to ensure timely submission of your appeal.

Start using our platform today to easily fill out FORM OMHA-100 for free!