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Form G-740S (03-13) G-740S (03-13) Patient's Request for Medicare Payment
Request for Medicare Payment
Form G-740S (03-13)
Request for Medicare Payment
OMB: 3220-0131
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OMB 3220-0131
ICR 201902-3220-005
IC 44217
Form G-740S (03-13) G-740S (03-13) Patient's Request for Medicare Payment
( )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3220-0131 can be found here:
2022-09-21 - Extension without change of a currently approved collection
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