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Get OK Franco Signor Final Settlement Detail Document

Final Settlement Detail Document Beneficiary Name Medicare Number Date of Incident 42 CFR 411. 37 c stipulates that Medicare will recognize a proportionate share of the necessary procurement costs incurred in obtaining a settlement. In order for Medicare to properly calculate the net refund it is due please supply the information outlined below. This information will also be used to update the beneficiary s records to show resolution of this matter. Total Amount of the Settlement Attorney Fee Amount Additional Procurement Expenses Please submit an itemized listing of these expenses Date the Case Was Settled Settlement Information Provided By Date The completed form should be sent to Medicare Secondary Payer Recovery Contractor NGHP PO Box 138832 Oklahoma City OK 73113 If you have any questions concerning this matter please call the Medicare Secondary Payer Recovery Contractor MSPRC at 1-866-677-7220 TTY/TDD 1-866-677-7294 for the hearing and speech impaired or you may contact us in writing at the address below. I f you contact us in writing please be sure to include the beneficiary s name and Medicare health insurance claim number. In order for Medicare to properly calculate the net refund it is due please supply the information outlined below. This information will also be used to update the beneficiary s records to show resolution of this matter. This information will also be used to update the beneficiary s records to show resolution of this matter. Total Amount of the Settlement Attorney Fee Amount Additional Procurement Expenses Please submit an itemized listing of these expenses Date the Case Was Settled Settlement Information Provided By Date The completed form should be sent to Medicare Secondary Payer Recovery Contractor NGHP PO Box 138832 Oklahoma City OK 73113 If you have any questions concerning this matter please call the Medicare Secondary Payer Recovery Contractor MSPRC at 1-866-677-7220 TTY/TDD 1-866-677-7294 for the hearing and speech impaired or you may contact us in writing at the address below. Total Amount of the Settlement Attorney Fee Amount Additional Procurement Expenses Please submit an itemized listing of these expenses Date the Case Was Settled Settlement Information Provided By Date The completed form should be sent to Medicare Secondary Payer Recovery Contractor NGHP PO Box 138832 Oklahoma City OK 73113 If you have any questions concerning this matter please call the Medicare Secondary Payer Recovery Contractor MSPRC at 1-866-677-7220 TTY/TDD 1-866-677-7294 for the hearing and speech impaired or you may contact us in writing at the address below. I f you contact us in writing please be sure to include the beneficiary s name and Medicare health insurance claim number. In order for Medicare to properly calculate the net refund it is due please supply the information outlined below. This information will also be used to update the beneficiary s records to show resolution of this matter. Total Amount of the Settlement Attorney Fee Amount Additional Procurement Expenses Please submit an itemized listing of these expenses Date the Case Was Settled Settlement Information Provided By Date The completed form should be sent to Medicare Secondary Payer Recovery Contractor NGHP PO Box 138832 Oklahoma City OK 73113 If you have any questions concerning this matter please call the Medicare Secondary Payer Recovery Contractor MSPRC at 1-866-677-7220 TTY/TDD 1-866-677-7294 for the hearing and speech impaired or you may contact us in writing at the address below. .

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