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This updated form is for an appeal and is not to be used when requesting a claim adjustment. Fill it out online, then print and mail it to the address indicated on the form.

This form is used by Medicare Part A providers who change the default or other contact who receives their interim rate, tentative settlement, NPR & NOC-PR determinations.

View this HRSA COVID-19 attestation.

This form is used by Medicare Part A providers for accelerated payments.