Get Form Hhs 725
Gs and Appeals specified in the QIC dismissal notice; Copy: Appellant APPEALING PARTY INFORMATION Appellant Name (The party appealing the QIC s dismissal) Street Health Insurance Claim (HIC) Number City State ZIP Code AL Telephone Number Alternate Telephone Number E-Mail BENEFICIARY INFORMATION Beneficiary Name (Leave blank if same as the appellant) Health Insurance Claim (HIC) Number City Street State ZIP Code AL Telephone Number Alternate Telephone Number E-Mail PROVIDER O.
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