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Get Request For Reconsideration Of Part A Health Insurance Benefits Form

Ype or print firmly. Leave the block empty if you cannot answer it. Take or mail the WHOLE form to your Social Security office which will be glad to help you. Please read the statement on the reverse side of page 2. 1. Beneficiary s Name 2. Health Insurance Claim Number 3. Representative s Name, if applicable Relative Attorney Other Person Provider Filing 4. PLEASE ATTACH A COPY OF THE NOTICE(S) YOU RECEIVED ABOUT YOUR CLAIM TO THIS FORM. 5. This Claim is for Inpatient.

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