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Get EHR Appeals Denial Cover Form 2013-2021

Red to EHR. The information in Green is optional. Patient and Hospital Information Submitted By: _______________________________________ Submitter Phone: ____________________________________ REQUIRED FOR MEDICAID FEE FOR SERVICE AND COMMERCIAL DENIALS List Dates Denied/Downgraded and Level of Care by Payor: Submission Date: ____________________________________ Patient Name: ________________________________________ Hospital Name: ______________________________________ Hospital Address: _______.

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