Hhs 722 Form PDF Details

The Department of Health and Human Services (HHS) provides critical oversight and administration of numerous programs, including Medicare, a vital component of the health care system in the United States. When a Medicare beneficiary or provider is involved in an appeal with the Office of Medicare Hearings and Appeals (OMHA) and passes away before the conclusion of their case, the HHS-722 form becomes an essential document. This "Request for Substitution of Party Upon Death of Party" form is designed to ensure that the appeals process can continue even after the death of the original party. It allows for a substitute party, with a genuine financial interest in the outcome of the appeal or legal authority to act on behalf of the deceased, to step in and either pursue or withdraw from the appeal. By providing options for how the substitute wishes to proceed, including whether to hold a hearing or base a decision on the written evidence, the form maintains the integrity of the appeals process. Moreover, it outlines the requirements and rights for representation, ensuring that the substituted party fully understands their role and the legal implications of their decisions. The inclusion of a Privacy Act statement underscores the form’s compliance with federal laws, safeguarding personal information while facilitating the necessary continuation of legal and administrative proceedings. This form epitomizes the balance between administrative efficiency and the compassionate consideration of individual circumstances following the death of a party involved in a Medicare appeal.

QuestionAnswer
Form NameHhs 722 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesE-Mail, APPELLANT, PSC, 1869

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of Medicare Hearings and Appeals

REQUEST FOR SUBSTITUTION

OF PARTY UPON DEATH OF PARTY

DECEASED PARTY INFORMATION

Name of Deceased Party

Social Security Number

Health Insurance Claim (HIC) Number

ALJ Appeal Number

Date of Birth

Date of Death

COMPLETE THIS SECTION IF THE DECEASED PARTY WAS THE APPELLANT

I have been informed that the appellant had requested an Administrative Law Judge (ALJ) hearing with the Office of Medicare Hearings and Appeals (OMHA), but died before action on the request was completed. I understand that the deceased appellant’s request for hearing will have to be dismissed unless an eligible person is substituted.

Please check one of the following:

I have a genuine financial interest in some or all of the deceased appellant’s claims. I have attached evidence of my legal authority to act on behalf of the deceased appellant.

No individual with a genuine financial interest in some or all of the deceased appellant’s claims exists. I am the provider or supplier who furnished the item(s) or service(s) involved in the appeal. I have attached evidence of the transaction(s).

Please check one of the following:

I do not wish to proceed with the hearing requested by the deceased, and I withdraw the request for hearing. I wish to proceed with the hearing. If you do wish to proceed with a hearing, please check one of the following:

I want the Administrative Law Judge to hold a hearing

I want the decision to be made based on the written evidence in the record without a hearing

COMPLETE THIS SECTION IF THE DECEASED PARTY WAS NOT THE APPELLANT

I have been informed that the deceased was a party to an appeal before an ALJ at the OMHA. I understand that the deceased party will no longer be a party to that appeal unless an eligible person is substituted. I have a genuine financial interest in the deceased party’s estate and have attached evidence of my legal authority to act on behalf of the deceased party.

I wish to attend the hearing.

I do not wish to attend the hearing.

SUBSTITUTE PARTY INFORMATION

Substitute Party Name (printed)

 

 

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

Relationship to Deceased

 

 

 

Date of Birth

 

Phone Number

 

 

 

 

 

 

 

 

 

(

)

 

 

Street

 

 

 

City

 

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

Alternate Phone Number

FAX Number

 

E-Mail

 

 

 

 

 

(

)

(

)

 

 

 

 

 

 

 

 

You have the right to be represented. If you are not represented, but would like to be, contact the Office of Medicare Hearings and Appeals Field Office assigned to your appeal for a list of legal referral and service organizations. If you are represented, and have not already done so, complete form CMS-1696 located at: http://www.cms.gov/cmsforms/downloads/cms1696.pdf or http://www.cms.gov/cmsforms/downloads/cms1696Spanish.pdf.

Substitute Party Signature

Date

PRIVACY ACT STATEMENT

The legal authority for the collection of information on this form is authorized by the Social Security Act (section 1155 of Title XI and sections 1852(g)(5), 1860D-4(h)(1), 1869(h)(I), and 1876 of Title XVIII). The information provided will be used to further document your appeal. The Social Security Number will be used to verify the identity of the individual appellant. Submission of the information requested on this form is voluntary, but failure to provide all or any part of the requested information may affect the determination of your appeal. Information you furnish on this form may be disclosed by the Office of Medicare Hearings and Appeals to another person or governmental agency only with respect to the Medicare Program and to comply with Federal laws requiring the disclosure of information or the exchange of information between the Department of Health and Human Services and other agencies.

HHS-722 (08/05)

PSC Publishing Services (301) 443-6740 EF

How to Edit Hhs 722 Form Online for Free

The procedure of filling in the CMS-1696 is really straightforward. Our team made sure our tool is easy to work with and can help complete just about any form within minutes. Listed below are the four simple steps you'll want to take:

Step 1: To begin, click the orange button "Get Form Now".

Step 2: When you have accessed your CMS-1696 edit page, you will notice all actions it is possible to use concerning your file within the top menu.

For every single part, add the data asked by the platform.

hhs gaps to complete

Write the necessary data in the I have been informed that the, I wish to attend the hearing, I do not wish to attend the hearing, SUBSTITUTE PARTY INFORMATION, Substitute Party Name printed, Social Security Number, Relationship to Deceased, Date of Birth, Street, City, Phone Number, State, ZIP Code, FAX Number, and Alternate Phone Number You have box.

Filling out hhs stage 2

Step 3: In case you are done, select the "Done" button to upload your PDF form.

Step 4: Prepare copies of your document. This will prevent possible challenges. We cannot read or distribute your data, so be certain it will be secure.

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