Fillable dab101 form

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DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHHS) / DEPARTMENTAL APPEALS BOARD Form DAB-101 (6/05) REQUEST FOR REVIEW OF ADMINISTRATIVE LAW JUDGE (ALJ) MEDICARE DECISION / DISMISSAL 1. APPELLANT (the party requesting review) 2. ALJ APPEAL NUMBER (on the decision or dismissal) 3. BENEFICIARY* 4. HEALTH INSURANCE CLAIM NUMBER (HICN)* *If the request involves multiple claims or multiple beneficiaries, attach a list of...
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