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Get CL-JM-B-4050 2015-2024

Insurance Claim (HIC) Number: Fax Number: ( ) Claim Date(s) of Service Phone Number: - ( ) - From: To: / Provider (NPI): / / CPT/HCPCS Code: / CPT/HCPCS Code: Provider Number (PTAN): INSTRUCTIONS: Providers who submit claims electronically may fax etc.). Refer to the Medicare Advisory and required. l required Local Coverage y and include it with your Please complete this form in its s listed below. purpose. Please ensure you complete the n (e.g. o e reports, discharge summar.

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