Hhs 722 Form – Fill Out and Use This PDF

Updated: Nov 11, 2026

The HHS-722 form is an official document from the Department of Health and Human Services focused on the Request for Substitution of Party Upon Death of Party. It's utilized in scenarios where an individual involved in a Medicare appeals process dies before their case is resolved, requiring a substitute party to step in. The form ensures that the appeal can continue, guided by clear protocols on how to proceed whether the deceased was the appellant or not.

For those needing to navigate this sensitive transition in an appeal process, detailed guidance and the option to proceed with or withdraw from the appeal are provided. Click the button below to fill out the form and ensure the continuation of the appeal process.

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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.

Question	Answer
Form Name	Hhs 722 Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	E-Mail, APPELLANT, PSC, 1869

How to Fill Out Form HHS-722

Form HHS-722 at a glance

What it is: Request for Substitution of Party Upon Death of Party is a form of the Department of Health and Human Services, Office of Medicare Hearings and Appeals.

Who signs: Sign under Substitute Party Signature and enter the Date.

An eligible person is substituted for a deceased party. If the deceased party was the appellant, the deceased appellant's request for hearing will have to be dismissed unless an eligible person is substituted; if the deceased party was not the appellant, the deceased party will no longer be a party to that appeal unless an eligible person is substituted. For a deceased party who was not the appellant, the eligible person must have a genuine financial interest in the deceased party's estate and must attach evidence of their legal authority to act on behalf of the deceased party.

A filled-in Form HHS-722 example: a daughter substitutes for a deceased appellant

Form HHS-722 example filled out, example: a daughter substitutes for a deceased appellant — Mary Sample, a deceased appellant's daughter, completes Form HHS-722. As the deceased was the appellant, she has a genuine financial interest and wants an ALJ hearing. Nothing goes in the group for a deceased party who was not the appellant because the deceased was the appellant. The picture shows the filled form; every value in it is made up.

How to fill out Form HHS-722, box by box

Deceased party information

Under DECEASED PARTY INFORMATION, enter the Name of Deceased Party, Social Security Number, Health Insurance Claim (HIC) Number, ALJ Appeal Number, Date of Birth and Date of Death.

Genuine financial interest or provider or supplier

Please check one of the following: if you have a genuine financial interest in some or all of the deceased appellant's claims, attach evidence of your legal authority to act on behalf of the deceased appellant.

If no individual with a genuine financial interest in some or all of the deceased appellant's claims exists, and you are the provider or supplier who furnished the item(s) or service(s) involved in the appeal, attach evidence of the transaction(s).

Proceed with the hearing or withdraw the request

Check one: I do not wish to proceed with the hearing requested by the deceased, and I withdraw the request for hearing; or I wish to proceed with the hearing. If you do wish to proceed with a hearing, check one: I want the Administrative Law Judge to hold a hearing, or 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

Complete this section if the deceased party was not the appellant: the deceased party will no longer be a party to that appeal unless an eligible person is substituted, and you have a genuine financial interest in the deceased party's estate and have attached evidence of your legal authority to act on behalf of the deceased party.

Check I wish to attend the hearing or I do not wish to attend the hearing.

Substitute party information

Under SUBSTITUTE PARTY INFORMATION, enter the Substitute Party Name (printed), Social Security Number, Relationship to Deceased, Date of Birth and Phone Number.

Enter the Street, City, State and ZIP Code, then the Alternate Phone Number, FAX Number and E-Mail.

More rules for Form HHS-722

If you are represented, and have not already done so, complete form CMS-1696. 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.

Sources

[1] Form HHS-722 (08/05), Request for Substitution of Party Upon Death of Party, Department of Health and Human Services, Office of Medicare Hearings and Appeals (the Official source link on this page).