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Patient Provider Dispute Resolution Initiation Form
ICR 202606-1210-003 · OMB 1210-0169 · Object 169565000.
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Document Metadata
| File Type | application/octet-stream |
|---|---|
| File Title | Patient Provider Dispute Resolution Initiation Form |
| Subject | Fillable form for consumers to start a payment dispute on a medical bill received from a provider, hospital, or facility that wa |
| Keywords | patient provider dispute resolution form |
| Author | CMS |
| Last Modified By | Adobe Acrobat Pro DC (32-bit) 21.7.20099 |
| File Modified | 2021-12-30 |
| File Created | 2021-12-21 |
| Conversion State | complete |