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PICA B. PLACE OF SERVICE 1a. INSURED’S I.D. NUMBER (For Program in Item 1) 4. INSURED’S NAME (Last Name, First Name, Middle Initial) …
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National Uniform Claim Committee CMS-1500 Claim
www.mdcodewizard.comNational Uniform Claim Committee . 1500 Health Insurance Claim Form . Reference Instruction Manual . for Form Version 02/12 . July 2018 . Version 6.0 7/18