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Is there a form I can use to ask for an appeal?

Is there a form I can use to ask for an appeal?

You can use the Medicare Summary Notice (MSN) to request an appeal (called a redetermination). You should carefully review the MSN and follow the instructions for requesting an appeal. You must circle the item/service that you disagree with, explain why you disagree, sign the MSN, and send it to the Medicare contractor identified in the "Appeal Information" section of the MSN. You can also write a letter. Your written request must include the following information:

  • Your name
  • Your Medicare Health Insurance Claim (HIC) number on your red, white and blue Medicare card
  • The specific service and/or items for which a redetermination is being requested
  • The date(s) of service
  • Your signature or the signature of your authorized or appointed representative

You should attach to your redetermination request any supporting documentation you believe may help your case. For example, you should include copies of your medical bills and copies of the MSN.

Medicare Appeals



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