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Get Etf Form 4307

Ible and numbers or write not eligible. send a copy of your card to ETF once you receive it. Medicare Claim Number is found here Medicare Effective Dates are found here If you do not have your card, contact the Social Security Administration at 1-800-772-1213 for these dates. If not eligible for MEDICARE, enter not eligible. 6. The subscriber must sign and date this form. If there is no signature or if it is signed by anyone other than the subscriber, the form cannot be proc.

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