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Get Hhs Civil Rights Information Request For Medicare Certification 2014

Healthcare providers applying f or participation in the Medicare Part A program must receive a civil rights clearance from OCR. Complete all fields and return this form, with the required policies and procedures, to your State Health Department, along w ith your other Medicare application materials. I. Healthcare Provider Information CMS Medicare Provider Number: Name of Facility: Address: Street Number and Name City or Town State or Province Admin istrator 's Name: Telephone: FAX: Contact .

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