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B 4050 2015-2023
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 summaries,
s to determine when
l
n is
l
. Do not use this fax cover sheet for any other
The
n must be faxed on the same day or up to two days prior to the electronic claim submission. The word ‘FAX’ must be
indicated in the
n record of the electronic claim submission.
This fax cover sheet must accompany...
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