Crosswalk

EXHIBIT A

Notice of Denial of Medical Coverage (or Payment) CMS-10065 IM
CROSSWALK
CURRENTLY
APPROVED
Non-discrimination
language on page 4:
CMS does not
discriminate in its
programs and activities.
To request this publication
in an alternative format,
please call 1-800MEDICARE or email:
[email protected].

CHANGE TO NOTICE
You have the right to
get Medicare
information in an
accessible format, like
large print, Braille, or
audio. You also have
the right to file a
complaint if you feel
you’ve been
discriminated against.
Visit
Medicare.gov/aboutus/accessibilitynondiscriminationnotice, or call 1-800MEDICARE (1-800633-4227) for more
information. TTY users
can call 1-877-4862048.

EXPLANATION
This is the updated
standardized
nondiscrimination
language required on
CMS forms and
notices.

Page 1 of 1