Date of the redetermination notice (mm/dd/yyyy): please include a copy of the notice with this request.
Evidence: if you have evidence to submit, attach the evidence to this form or attach a statement explaining what you intend to submit and when you intend to submit it.
Later evidence: you may also submit additional evidence at a later time, but all evidence must be received prior to the issuance of the reconsideration.
Overpayment (for providers and suppliers only): does this appeal involve an overpayment? Yes or No.
Person appealing: Beneficiary, Provider/Supplier or Representative.
Optional: email of person appealing and date of appeal (mm/dd/yyyy).
| Question | Answer |
|---|---|
| Form Name | Form CMS-20033 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 20 |
| Avg. time to fill out | 4 min |
| Edition | 01/20 |
| Issuing agency | Centers for Medicare & Medicaid Services |
| Late filing | Include your reason if you received your redetermination notice more than 180 days ago |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | CMS-20033, CMS20033, CMS 20033, Form CMS-20033, Medicare Reconsideration Request Form |
| Official source | Form CMS-20033 (Rev 01/20), Centers for Medicare & Medicaid Services |
Form Cms 20033 isn’t the one you’re looking for?