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Publications

Forms

Medicare Quality of Care Complaint Form
Clinical Laboratory Improvement Amendments Of 1988 (ClIA) Application For Certification
Health Insurance Claim Form
Medicare/Medicaid Certification and Transmittal
Responsibilities of Medicare Participating Hospitals In Emergency Cases Investigation Report
Health Insurance Benefit Agreement
Health Insurance Benefit Agreement-Rural Health Clinic
Monthly Intermediary Report on Medicare Secondary Payer Savings
Monthly Carrier Report on Medicare Secondary Payer Savings
HHA Survey and Deficiencies Report
Regional Office Request For Additional Information
Appointment of Representative
Attending Physicians Statement and Documentation For Medicare Emergency
Transmittal and Notice of Approval Of State Plan Material
Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services
Portable Xray Survey Report
Outpatient Physical Therapy - Speech Pathology Survey Report
Request For Hearing - Part B Medicare Claim
Carrier or Intermediary Request For SSO Assistance
Notice of Exclusions From Medicare Benefits (NEMB)
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