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CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL ...

CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL Please indude the original preauthorization request form in lieu of PART A The issue of this Form is not to be taken as an admission of liability ... Number of Inpatient beds Enter the number of inpatient beds Digits f) Facilities available in the hospital Indicate facilities available in the ...

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  Hospital, Part, Inpatient, Part b

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