Get CMS-L564 2010
Ity Administration Employer’s Name and Address: Date: Employee’s Name: Employee’s Social Security Number: Claimant’s Name: Claim Number: Dear Sir/Madam: We need the following information regarding the above claimant. Please answer the questions below, sign and date this letter and return it in the enclosed envelope. You may call ____________________________________________________ at the above telephone number if you have any questions. Sincerely, Office Manager 1. Is (or was) the.
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