Part A Reconsideration Input Record {CMS-352} | Pdf Fpdf Doc Docx | Official Federal Forms

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Part A Reconsideration Input Record {CMS-352} | Pdf Fpdf Doc Docx | Official Federal Forms

Part A Reconsideration Input Record {CMS-352}

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

Alternate TextLast updated: 5/2/2006

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PART A RECONSIDERA TION INPUT RECORD RECORD IDENTIFIER H.I. CLAIM NUMBER ADMISSION/HHA DATE (MMDDYYYY) A                       SURNAME GIVEN NAME RECON. FILED (MMDDYYYY)                             PR OVIDER NUMBER REQUESTED BY ORIG. AMT. APPEALED BLANK - BENEFICIARY 1. ATTORNEY 3. PROVIDER         2. RELATIVE 4. OTHER        RESIDENT INTER. RESIDENT INTER. RECEIPT DATE- (MMDDYYYY)                RECON. INTER.      RECON. INTER. RECEIPT DATE - (MMDDYYYY) AMT. AFTER RECON.                 RECON. COMPLETED DATE - (MMDDYYYY) RECON. DECISION AMT. AFTER RECON. CODE 1. AFF. 3. P/R 5. DIS 1. UNDER $100 4. NONE 2. $100 TO $1000 5. UNKNOWN 2. REV. 4. WD            3. OVER $1000 GOOD CAUSE TRANSFER/ACTION WAIVER OF LIABILITY ISSUE 1. YES 1. YES     CONGRESSIONAL INTEREST 1. YES  American LegalNet, Inc. www.USCourtForms.comForm CMS-352 (6-86)

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