Monthly Carrier Report On Medicare Secondary Payer Savings {CMS-1564} | Pdf Fpdf Doc Docx | Official Federal Forms

 Official Federal Forms /  Centers For Medicare And Medicaid Services /
Monthly Carrier Report On Medicare Secondary Payer Savings {CMS-1564} | Pdf Fpdf Doc Docx | Official Federal Forms

Monthly Carrier Report On Medicare Secondary Payer Savings {CMS-1564}

This is a Official Federal Forms form that can be used for Centers For Medicare And Medicaid Services.

Alternate TextLast updated: 4/3/2007

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<document>DEPARTMENTOFHEALTHANDHUMANSERVICESCENTERSFORMEDICARE&amp;MEDICAIDSERVICESCARRIERNAME10.DollarValue (Lines2+4+6+8)FORMCMS-1564(11-97)Totals 9.Number (Lines1+3+5+7)8.DollarValueUnpaid(CostAvoided) MSPClaims 1.Number REMARKS SIGNATURESpecialProjects 7.Number6.DollarValuePartialRecoveries 5.Number4.DollarValueFullRecoveries 3.Number2.DollarValueTOTAL(i)theHonorableCountyofinroom.oradjourneddate,totestifyandgiveevidenceasawitnessinthisactiononthepartofthethepartyonwhosebehalfthissubpoenawasissuedforamaximumpenaltyof$50andalldamagessustainedasaresultofyourfailuretocomply.THEPEOPLEOFTHESTATEOFNEWYORKTOCourtinBLACKLUNG&amp;VAWORKER'SCOMP...MEDICARESECONDARYPAYERSAVINGS....(ii)Yourfailuretocomplywiththissubpoenaispunishableasacontemptofcourtandwillmakeyouliableto.Witness,HonorableMONTHLYCARRIERREPORTON......,.onthe.TITLE.County,.WORKINGAGED..NUMBER....(iii)GREETINGS: WECOMMANDYOU,thatallbusinessandexcusesbeinglaidaside,youandeachofyouattendbefore..dayof.locatedat..dayof...........ESRD.,atthe(iv).20.STATE.,.s)20..,.at...(Attorneymustsignaboveandtypenamebelow)Attorney(s)forOfficeandP.O.AddressTelephoneNo.:FacsimileNo.:E-MailAddress:.. Mobile:AUTO/NFLTTel.No.:(v)Courto'clockintheREPORTINGPERIOD(MO.&amp;YR.),oneoftheJusticesoftheDATEDISABLEDLIABILITYnoon,andatanyrecessed(vi)AmericanLegalNet,Inc.www.USCourtForms.com(vii),</document>

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