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WebForm CMS 10123-NOMNC (Approved 12/31/2011) OMB approval 0938-0953 . If You Miss The Deadline to Request An Immediate Appeal, You May Have Other Appeal Rights: • If you have Original Medicare: Call the QIO listed on page 1. • If you belong to a Medicare health plan: Call your plan at the number given below. WebOMB No. 1545-0008 . b . Employer identification number (EIN) c . Employer’s name, address, and ZIP code. d . Control number. e . Employee’s first name and initial. ... 11 Nonqualified plans 12a See instructions for box 12. C o d e 12b. C o d e 12c. C o d e 12d. C o d e 13. Statutory employee Retirement plan. Third-party sick pay 14 Other. WebView Details. Request a review. Learn more green thumb leicester