Request to Withdraw

Please fill out the form below to withdraw your appeal request. Withdrawing your appeal request means your appeal will be dismissed.

Case No. *

Hearing Officer

Hearing Date

Month

Day

Year

Beneficiary First Name *

Beneficiary Last Name *

Representative name

Provider Name

Address

Address 2

Phone Number *

Phone Number

Email address

• Please state why you are withdrawing your request for appeal *

(ie: the issue was resolved, you no longer wish to pursue the appeal, etc.)

Submitter Information

Only the petitioner or their representative has the right to withdraw an appeal.

Submitter First Name *

Submitter Last Name *

Submitter Email address *

I attest *

I attest that I am the above-mentioned beneficiary or provider or an authorized representative for the beneficiary or provider requesting to withdraw my fair hearing request. I understand that submitting this request to withdraw will result in dismissal of my appeal.

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Request to Withdraw

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