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Get And Sign Part B Notification Form 2016-2021

Is properly recorded and applied. Provider/Physician/Supplier Name Address Provider/Physician/Supplier Number NPI Tax ID # Contact Person Phone Number Amount of Check $ Check # Check Date REFUND INFORMATION For each claim, provide the following: Patient Name HIC Number Medicare Claim Number (ICN) Date of Service Claim Amount Refunded $ Reason Code for Adjustment (Select reason code from list below. Use one reason per claim) (Please list all claim numbers involved. Attach separate...

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