Doctor or Facility who provided the care or services - AARP Medicare Plans
Doctor or Facility who provided the care or services Name___________________________________________ Address_________________________________________ City _______________ State _______ ZIP___________ Phone Number___________________________________ Doctor or Facility who referred you for the care or services, (if applicable) Name___________________________________________ Address_________________________________________ City _______________ State _______ ZIP___________ Phone Number___________________________________
What city and country were you in when you received medical care or supplies? _________________________________________________________________________________
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