Request to Cancel

Please fill out the form below to submit a request to cancel a hearing

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 requesting your hearing be canceled *

I Attest *

that I am the above-mentioned beneficiary or provider or an authorized representative for the beneficiary or provider requesting to cancel my fair hearing.

Do you wish to withdraw your appeal? *

Please state why you are withdrawing your request for appeal

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

Attest to withdraw

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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