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Get Petici N Del Paciente Para Pagos De Medicare - Centers For ... - Cms

NES POR FAVOR ESCRIBA A MAQUINA O CON LETRA DE IMPRENTA BENEFICIOS DE SEGURO M DICO DE LA LEY DE SEGURO SOCIAL NOTA: Cualquiera que falseifique o provea informaci n falsa en la informaci n esencial requerida en este formulario est sujeto a una multa y prisi n bajo la Ley Federal. No se pagar nada de los beneficios de Medicare Parte B a no ser que este formulario se reciba como requieren las regulaciones y leyes existentes (20 CFR 422.510). Nombre del Beneficiario que Figura en la Tarjeta.

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