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Get Cms 20034 Ab Fillable Form

N determination issued by a Qualified Independent Contractor (QIC) J Part B (Amount in controversy must be $100 or more.) Send copies of this completed form to: Original Office of Medicare Hearings and Appeals Field Office specified in the QIC Reconsideration Notice Copy Appellant Copy All other parties Failure to send a copy of this completed request to the other parties to the appeal will delay the start date of your appeal. Did you send all required copies? J Yes J No Appellant (.

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