Form CMS-1500 (02-12) CMS-1500 (02-12) Health Insurance Claim Form

Request for Medicare Payment

CMS 1500 (02-12)

Request for Medicare Payment

OMB: 3220-0131

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PLEASE PRINT OR TYPE

APPROVED OMB-0938-1197 FORM 1500 (02-12)


File Typeapplication/pdf
File Modified2015-09-15
File Created2014-03-31

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