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Does request involve multiple claims If yes a list of claims must be attached. Yes No beneficiaries If yes a list of beneficiaries their HICNs and the dates of service must be attached. HHS-725 8/05 PAGE 1 OF 3 C. Did the beneficiary assign his or her appeal rights to you as the provider/ supplier If yes you must complete and attach form CMS-20031. For use by a party to a dismissal issued by a Qualified Independent Contractor QIC. The remaining a...
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