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If You Miss The Deadline to Request An Immediate Appeal, You May Have
Other Appeal Rights:
• If you have Original Medicare: Call the QIO listed on page 1.
• If you belong to a Medicare health plan: Call your plan at the number given below.
Plan contact information _____________________________________________
_________________________________________________________________
SAMPLE
Additional Information (Optional):
Ó MedForms, Inc. 2024
Please sign below to indicate you received and understood this notice.
I have been notified that coverage of my services will end on the effective date indicated on
this notice and that I may appeal this decision by contacting my QIO.
Signature of Patient or Representative Date
Form CMS 10123-NOMNC (Approved 12/31/2011) OMB approval 0938-0953
