MyMedicare Incentives Review of decision form (IP034)

Use this form if you disagree with a program decision made under MyMedicare Incentives.

Download and complete the MyMedicare Incentives Review of decision form.

You must upload the form and supporting documents through HPOS messages within 28 days of the decision.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 26 September 2024.
QC 80036