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Black Ball Ferry Parking Victoria

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PLEASE PRINT OR TYPE APPROVED OMB 0938 1197 FORM 1500 02 12 S Page 4 b NPI APPROVED OMB 0938 1197 FORM 1500 02 12 PATIENT AND INSURED Form #. CMS 1500 ; Form Title. Health Insurance Claim Form ; Revision Date. 2012-02-01 ; O.M.B. #. 0938-1197 ; O.M.B. Expiration Date. 2024-12-31 ...

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Black Ball Ferry Parking VictoriaINSTRUCTIONS FOR COMPLETING THE FORM: A brief description of each data ... Column B: enter the correct CMS/OWCP standard "place of service" (POS) code ... PLEASE PRINT OR TYPE FORM HCFA 1500 12 90 FORM RRB 1500 FORM OWCP 1500 APPROVED OMB 0938 0008 Page 2 BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other ... Birdease Event Software IMG 3999 On Coho Ferry Black Ball Ferry Line Arriving At Flickr

CMS 1500

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