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 B 4050 2015-2023

B 4050 2015-2023

Use a cl jm b 4050 2015 template to make your document workflow more streamlined.

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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