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0938-1197 PATIENT S REQUEST FOR MEDICAL PAYMENT IMPORTANT PLEASE READ THE ATTACHED INSTRUCTIONS PRIOR TO SUBMITTING A CLAIM TO MEDICARE SEND ONLY THE COMPLETED FORM TO YOUR MEDICARE ADMINISTRATIVE CONTRACTOR Include a copy of the itemized bill and any supporting documents. Make a copy of your claim submission for your records and allow at least 60 days for Medicare to receive and process your request. Reference the Medicare Administrative Contractor Address Table for the correct address to mail...

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