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Get CMS-20031 2018-2024

Or an item or service. If your provider accepts your appeal rights, he or she cannot charge you for this item or service (except for applicable coinsurance and deductible amounts) even if Medicare will not pay the claim. Please see the back for more information before you complete this form. Section I must be completed and signed by the beneficiary. SECTION I: TRANSFER OF APPEAL RIGHTS 1. Name of Patient (Please Print) 3. Phone Number (Include area code) 2. Medicare Number 4. Address (Street) .

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