Skip to main content


U.S. flag
      An official website of the United States government
              Here’s how you know
        Here’s how you knowDot gov**Official websites use .gov**
                 A **.gov** website belongs to an official government organization in the United States.
                  HTTPS**Secure .gov websites use HTTPS**
                 A **lock** (A locked padlock) or **https://** means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites. 
  Menu Close
          Enter the terms you wish to search for.
    Search
        








  
  
    

  
      

                                      About HHS
    
                        
                              
      
      
      Programs & Services
    
                        
                              
      
      
      Grants & Contracts
    
                        
                              
      
      
      Laws & Regulations Breadcrumb
    Home
                              About
                              Agencies
                              DAB
                              Different Appeals at DAB
                              Appeals to ALJ
                              Briefing Forms - IG Appeals Before Administrative Law Judges
 Navigate to:
  Departmental Appeals Board (DAB)
    
                                                  
                                                    
            
      
      
      
      Filing an Appeal Online
                                            
            
            DAB E-File
    
                                                  
                              
            
      
      
      
      Medicare Operations Division (MOD) E-File
    
                                                  
                                                                          
                          
      
      
      
      Different Appeals at DAB
                                            
            
            Appeals to DAB Administrative Law Judges (ALJs)
                          
            
            Forms
    
                                                  
                              
            
      
      
      
      Procedures
    
                                                                
                                                    
            
      
      
      
      Appeals to Board
                          
            
            Practice Manual
    
                                                  
                              
            
      
      
      
      Guidelines
    
                                                  
                              
            
      
      
      
      Regulations
    
                                                  
                              
            
      
      
      
      National Coverage Determination Complaints
    
                                                                
                                                    
            
      
      
      
      Appeals to the Medicare Appeals Council (Council)
                          
            
            Forms
    
                                                  
                              
            
      
      
      
      Fully Integrated Duals Advantage (FIDA) Demonstration Project
    
                                                  
                                                    
            
      
      
      
      Alternative Dispute Resolution Services
                                            
            
            Sharing Neutrals
    
                                                  
                              
            
      
      
      
      ADR Training
    
                                                  
                              
            
      
      
      
      Other ADR Services
    
                                                  
                                                    
            
      
      
      
      DAB Decisions
                                            
            
            Board Decisions
    
                                                  
                              
            
      
      
      
      DAB Administrative Law Judge (ALJ) Decisions
    
                                                  
                              
            
      
      
      
      Medicare Appeals Council (Council) Decisions
    
                                    
                              
            
      
      
      
      Stakeholder Feedback
    
                                                  
                                                    
            
      
      
      
      Careers
                                            
            
            Open Career Opportunities
    
                                                  
                              
            
      
      
      
      Internships & Externships
    
                                                  
                                                    
            
      
      
      
      About DAB
                                            
            
            Organizational Overview
    
                                                  
                              
            
      
      
      
      Who are the Judges?
    
                                                  
                              
            
      
      
      
      DAB Divisions
    
                                                  
                              
            
      
      
      
      Contact DABLanguages
      English
    
                        
                                            
      
      
      Español (Spanish)Text resize icon

                    




Briefing Forms - IG Appeals Before Administrative Law Judges








  
  
    

  
      



IG All 1128IG All 1128 - Word
	1128(a)(1) 5 Years1128(a)(1) 5 Years - Word
	1128(a)(1) and or (a)(3) 5 Years1128(a)(1) and or (a)(3) 5 Years - Word
	1128(a)(1) and or (a)(3) More than 5 Years1128(a)(1) and or (a)(3) More than 5 Years - Word
	1128(a)(1) More than 5 Years1128(a)(1) More than 5 Years - Word
	1128(a)(2) 5 Years1128(a)(2) 5 Years - Word
	1128(a)(2) More than 5 Years1128(a)(2) More than 5 Years - Word
	1128(a)(3) 5 Years1128(a)(3) 5 Years - Word
	1128(a)(3) More than 5 Years1128(a)(3) More than 5 Years - Word
	1128(a)(4) 5 Years1128(a)(4) 5 Years - Word
	1128(a)(4) More than 5 Years1128(a)(4) More than 5 Years - Word
	1128(b)(1) 3 Years1128(b)(1) 3 Years - Word
	1128(b)(1) More than 3 Years1128(b)(1) More than 3 Years - Word
	1128(b)(2) 3 Years1128(b)(2) 3 Years - Word
	1128(b)(2) More than 3 Years1128(b)(2) More than 3 Years - Word
	1128(b)(3) 3 Years1128(b)(3) 3 Years - Word
	1128(b)(3) More than 3 Years1128(b)(3) More than 3 Years - Word
	1128(b)(4) Exclusion, Coterminous with Loss of License1128(b)(4) Exclusion, Coterminous with Loss of License - Word
	1128(b)(4) Exclusion, Period of Years, & Coterminous with Loss of License1128(b)(4) Exclusion, Period of Years, & Coterminous with Loss of License - Word
	1128(b)(5) Exclusion Period Coterminous with Suspension or Exclusion Term1128(b)(5) Exclusion Period Coterminous with Suspension or Exclusion Term - Word
	1128(b)(5) Exclusion, Period of Years, & Coterminous with Suspension or Exclusion Term1128(b)(5) Exclusion, Period of Years, & Coterminous with Suspension or Exclusion Term
	Exhibit List - IG or PetitionerExhibit List - IG or Petitioner - WordIf you need assistance in selecting the briefing form appropriate for your appeal, then please call the Departmental Appeals Board, Civil Remedies Division, at (202) 795-7490.

                    
  


Content created by Departmental Appeals Board (DAB) Content last reviewed March 28, 2023 Back to top
    Contact HHS
    
                        
                                            
      
      
      Careers
    
                        
                                            
      
      
      HHS FAQs
    
                        
                                            
      
      
      Nondiscrimination NoticeHHS Archive
    
                        
                                            
      
      
      Accessibility Statement
    
                        
                                            
      
      
      Privacy Policy
    
                        
                                            
      
      
      Viewers & PlayersBudget/Performance
    
                        
                                            
      
      
      Inspector General
    
                        
                                            
      
      
      Web Site Disclaimers
    
                        
                                            
      
      
      EEO/No Fear ActFOIA
    
                        
                                            
      
      
      The White House
    
                        
                                            
      
      
      USA.gov
    
                        
                                            
      
      
      Vulnerability Disclosure Policy
        Sign Up for Email Updates

Receive the latest updates from the Secretary, Blogs, and News Releases.

Sign Up
  HHS Headquarters
          200 Independence Avenue, S.W.
                  Washington, D.C. 20201
                  Toll Free Call Center: 1-877-696-6775​