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