Monthly Carrier Report On Medicare Secondary Payer Savings
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Monthly Carrier Report On Medicare Secondary Payer Savings Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Monthly Carrier Report On Medicare Secondary Payer Savings, CMS-1564, Official Federal Forms Centers For Medicare And Medicaid Services,
DEPARTMENTOFHEALTHANDHUMANSERVICESCENTERSFORMEDICARE&MEDICAIDSERVICESCARRIERNAME10.DollarValue (Lines2+4+6+8)FORMCMS-1564(11-97)Totals 9.Number (Lines1+3+5+7)8.DollarValueUnpaid(CostAvoided) MSPClaims 1.Number REMARKS SIGNATURESpecialProjects 7.Number6.DollarValuePartialRecoveries 5.Number4.DollarValueFullRecoveries 3.Number2.DollarValueTOTAL(i)theHonorableCountyofinroom.oradjourneddate,totestifyandgiveevidenceasawitnessinthisactiononthepartofthethepartyonwhosebehalfthissubpoenawasissuedforamaximumpenaltyof$50andalldamagessustainedasaresultofyourfailuretocomply.THEPEOPLEOFTHESTATEOFNEWYORKTOCourtinBLACKLUNG&VAWORKER'SCOMP...MEDICARESECONDARYPAYERSAVINGS....(ii)Yourfailuretocomplywiththissubpoenaispunishableasacontemptofcourtandwillmakeyouliableto.Witness,HonorableMONTHLYCARRIERREPORTON......,.onthe.TITLE.County,.WORKINGAGED..NUMBER....(iii)GREETINGS: WECOMMANDYOU,thatallbusinessandexcusesbeinglaidaside,youandeachofyouattendbefore..dayof.locatedat..dayof...........ESRD.,atthe(iv).20.STATE.,.s)20..,.at...(Attorneymustsignaboveandtypenamebelow)Attorney(s)forOfficeandP.O.AddressTelephoneNo.:FacsimileNo.:E-MailAddress:.. Mobile:AUTO/NFLTTel.No.:(v)Courto'clockintheREPORTINGPERIOD(MO.&YR.),oneoftheJusticesoftheDATEDISABLEDLIABILITYnoon,andatanyrecessed(vi)AmericanLegalNet,Inc.www.USCourtForms.com(vii),
