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DEPARTMENT OF HEALTH AND HUMAN SERVICES DHHS / DEPARTMENTAL APPEALS BOARD Form DAB-101 08/09 REQUEST FOR REVIEW OF ADMINISTRATIVE LAW JUDGE ALJ MEDICARE DECISION / DISMISSAL 1. APPELLANT the party requesting review 2. ALJ APPEAL NUMBER on the decision or dismissal 3. BENEFICIARY 4. HEALTH INSURANCE CLAIM NUMBER HICN If the request involves multiple claims or multiple beneficiaries attach a list of beneficiaries HICNs and any other information to identify all claims being appealed* 5. PROVIDER...