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Get Wps Redetermination Form 2013-2024

7-7861 Date Requested ________________________________________________________ DCN/Claim# (claim being appealed) ________________________________________ Does this appeal involve an overpayment? *Please provide a copy of the overpayment letter. YES* NO Patient Name ___________________________________________________________ Medicare Health Insurance Claim (HIC) Number ______________________________ Date(s) of service ________________________________________________________ Item(s) and/or serv.

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