Adjustment/void Request Form - Wyoming Medicaid
Adjustment/void Request Form. EXHIBIT 6.9. ADJUSTMENT/VOID REQUEST FORM. SECTION A: CHECK BOX 1a), 1b) OR 2) 1a) CLAIM ADJUSTMENT: Attach a copy of . the claim with corrections made in BLUE ink. DO NOT USE HIGHLIGHTER 1b) VOID CLAIM: Attach a copy of the claim or Remittance Advice. Complete Sections B and C. ................
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