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Get Palmetto GBA Claims Processing PWK Fax Cover Sheet 2019-2024

Being submitted. This form should not be submitted prior to ling the claim. Instructions for Completing the Medicare PWK Fax Cover Sheet When Submitting Additional Documentation ACN: (Exactly as entered in the PWK loop on the claim) ICN: Bene ciary Last Name: Bene ciary First Name: Medicare ID: Date of Service Start: Date of Service End: Total Claim Billed Amount: / / / / Billing Providers Name Billing Provider Phone Number: ( NPI: ) - Total Number of Documentation Pages:.

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