CUT0124 Outpatient PRE Treatment Authorization Program OPAL Initial
Appointed Representative Form. Web form approved omb no. Web appointment of representative name of party medicare number (beneficiary as party) or national provider identifier (provider or supplier as party) section 1:
CUT0124 Outpatient PRE Treatment Authorization Program OPAL Initial
Your representative must complete sections 5 and 7 of this form. Web contact your local hearing office and request an invitation to enroll. Web appointment of representative name of party medicare number (beneficiary as party) or national provider identifier (provider or supplier as party) section 1: Web form approved omb no. Appointment of representative to be completed by the. You can use our electronic version of the form by asking your. If you are using this form to appoint a representative, you must complete sections 1, 2, and 3.
Web appointment of representative name of party medicare number (beneficiary as party) or national provider identifier (provider or supplier as party) section 1: Web contact your local hearing office and request an invitation to enroll. You can use our electronic version of the form by asking your. If you are using this form to appoint a representative, you must complete sections 1, 2, and 3. Appointment of representative to be completed by the. Your representative must complete sections 5 and 7 of this form. Web form approved omb no. Web appointment of representative name of party medicare number (beneficiary as party) or national provider identifier (provider or supplier as party) section 1:
