Appellant Details

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a United States law that provides data privacy and security provisions for the handling of medical information. The HIPAA legislation includes the formation of the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR), which is responsible for enforcing compliance with the Privacy Rule. One important piece of documentation under HIPAA is the Health Care Provider Form 722, more commonly referred to as the “HHS 722 form”. This form is used by healthcare providers to request authorization from health insurance carriers to disclose protected health information (PHI) for treatment, payment, or healthcare operations purposes.

If you wish to first find out how much time you need to fill out the hhs 722 form and the number of pages it's got, here's some general data that will be helpful.

QuestionAnswer
Form NameHhs 722 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesXVIII, OMHA, PSC, cms

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.hhs.cms.gov/forms .

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 (8/05)

PSC Media Arts (301) 443-1090 EF

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