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