Crosswalk

CMS-10065 - Crosswalkv508.pdf

Hospital Notices: IM / DND (CMS-10065/10066)

Crosswalk

OMB: 0938-1019

Document [pdf]
Download: pdf | pdf
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


File Typeapplication/pdf
File TitleChange Crosswalk to CMS-10003
SubjectCMS-10003, IDN, NDMCP
AuthorCMS
File Modified2022-08-11
File Created2022-07-21

© 2024 OMB.report | Privacy Policy