Official Federal Forms
Centers For Medicare And Medicaid Services
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Last updated: 11/8/2010
ALJ Medicare Case Folder (CMS) {CMS-3509}
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Description
ALJ MEDICARE CASE FOLDER (CMS) This file must be routed to the following address upon completion of OHA action: Supervisor, ALJ Department Empire Medicare Services 2651 Strang Boulevard Yorktown Heights, New York 10598 If the original case file is separated for adjudication, please include a copy of this form in each case file. If you have any questions about this case file, please contact the originating contractor. Contractor Name & Contractor Number Address Phone & Contact Name This information MUST be completed by the originating contractor. CMS-3509 (08-02) American LegalNet, Inc. www.USCourtForms.com
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