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CLAIM CODES (Designated by NUCC) READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORMPATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. Sign and date section Ensure all supporting documents are sent to your designated MAC Welcome to Medicare Medicare 10d. 10d. Include the Electronic Funds Transfer (EFT) Authorization Agreement (when applicable) with your enrollment application with a voided check or bank letter. I also request payment of government benefits either to myself or to the party who accepts assignment below %PDF %âãÏÓobj > endobjobj >/Filter/Flate ode/ID[EFD4ECC2EF87AE8>C8FD4CF8F83DAFD>]/Index[]/Info Centers for Medicare & Medicaid Services CLAIM CODES (Designated by NUCC) READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORMPATIENT’S OR AUTHORIZED PERSON’S Welcome to Medicare Medicare Centers for Medicare & Medicaid Services %PDF %âãÏÓobj > endobjobj >/Filter/Flate ode/ID[EFD4ECC2EF87AE8>C8FD4CF8F83DAFD>]/Index[ HomeCenters for Medicare & Medicaid Services CMSEnter your NPI(s) in the applicable section(s).
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