Request to Withdraw

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

(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.
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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