Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority & Invoice for Travel by Ambulance or other Hired Vehicle; Authorization & Invoice for Medical....
Claim for Payment of Cost of Unauthorized Medical Services; Funeral Arrangements; Authority & Invoice for Travel by Ambulance or other Hired Vehicle; Authorization & Invoice for Medical....
OMB: 2900-0080
IC ID: 42186
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0080 can be found here: