Claim Form and Instructions

Dec 01, 2020 · The Lines 1, 2, 3, and 4 tab shows the same categories as the SSA tab, but they have been rearranged to match with the numbered lines on the Claim Form Summary page. Service Providers must fill out Columns D, E, F and G. The formulas in Col H have been pre-filled. Service Providers will need to include the formulas if additional lines are added. ................
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