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Medicare Appeals Forms
http://www.medicare.gov/basics/forms/default.asp
Source: United States Department of Health and Human Services, Centers for Medicare and Medicaid Services

Links to online forms people can use in Medicare-related appeals. Forms include: Appointment of Representative, Request for Review of Part B Medicare Claim, Request for Hearing - Part B Medicare Claim, Request for Reconsideration of Part A Health Insurance Benefits, Request for Part A Medicare Hearing by an Administrative Law Judge, and Request for Part B Medicare Hearing by an Administrative Law Judge. Some forms are available in Spanish. Special tools are also provided to permit access to the forms by persons with visual disabilities.
full description

• Where can I get the forms I need to appeal Medicare coverage decisions?
• What can I do if Medicare won't pay for a health care service or item I received?
• What can I do if my Medicare Managed Care Plan won't provide me the care I think I need?
• How do I appeal Medicare's decision not to pay or provide a health service or item?