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  • Medicare Check List

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    intlopt
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    MEDICARE CHECK LIST LAST NAME______________________FIRST__________________MI___ medicare #_____________________................_____________________ ____________________________(state of Florida primary!!) date of birth / _________ / ____________ doctors / full name of ophthalmologist who performed surgery Date of Surgery Co-Insurance and policy number____________________________________. Please copy Medicare Name and Number exactly as they

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    MEDICARE CHECK LIST

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    MEDICARE CHECK LIST LAST NAME______________________FIRST__________________MI___ medicare #_____________________................_____________________ ____________________________(state of Florida primary!!) date of birth / _________ / ____________ doctors / full name of ophthalmologist who performed surgery Date of Surgery Co-Insurance and policy number____________________________________. Please copy Medicare Name and Number exactly as they

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    Attribution Non-Commercial (BY-NC)
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    Markieren Sie unangemessene Inhalte
    11 Ansichten2 Seiten

    Medicare Check List

    Hochgeladen von

    intlopt
    MEDICARE CHECK LIST LAST NAME______________________FIRST__________________MI___ medicare #_____________________................_____________________ ____________________________(state of Florida primary!!) date of birth / _________ / ____________ doctors / full name of ophthalmologist who performed surgery Date of Surgery Co-Insurance and policy number____________________________________. Please copy Medicare Name and Number exactly as they

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
    Markieren Sie unangemessene Inhalte
    von 2

    MEDICARE CHECK LIST

    LAST NAME______________________FIRST_________________________MI____

    MEDICARE #_________________________________________

    FULL ADDRESS_________________________________________________________

    _________________________________________________(state of Florida primary!!)

    Date of Birth______/__________/____________

    DOCTOR______________________________________________________________

    Full name of ophthalmologist who performed surgery

    Date of Surgery OD__________________ OS_______________________

    Co-Insurance & Policy Number______________________________________________

    Patient Status: Single Married Widow Student Other (circle one)

    Please copy Medicare Name & Number exactly as they appear on card…..or photocopy

    Any questions, call Ron

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