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Get Department Of Health And Human Services Form 0938 0950

DePartMeNt oF HeaLtH aNd HUMaN SerViCeS CeNterS For MediCare MediCaid SerViCeS Form approved oMB No. 0938-0950 APPOINTMENT OF REPRESENTATIVE NaMe oF Party MediCare or NatioNaL ProVider ideNtiFier NUMBer SECTION I APPOINTMENT OF REPRESENTATIVE To be completed by the party seeking representation i.e. the Medicare beneficiary the provider or the supplier i appoint this individual to act as my representative in connection with my claim or asserted ri.

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