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Administrative Simplification Compliance Act Waiver Request Form Advance Beneficiary Notice (ABN) (CMS R-131-G and CMS R-131-L) Appeals Request Form Appointment of Representative Form (CMS-1696) Extended Repayment Plan Request Form EDI Enrollment Form EDI Registration for New Submitters for (Indiana and Kentucky Providers) EDI Registration for Existing Submitters for only (Indiana and Kentucky Providers) Electronic Remittance Advice Request (Indiana and Kentucky Providers) Electronic Remittance Advice Request (New York Providers) Express Plus Request Form (Indiana and Kentucky Providers) Medicare Correspondence Request Form Medicare Hearing by an Administrative Law Judge Request Form (CMS-20034) Medicare Monthly Review Hard Copy Subscription Form Medicare Physician Fee Schedule/Enrollment Package Request Form Medicare Secondary Payer Offset Request Form (Connecticut, Indiana, Kentucky and New York Providers) Medicare Secondary Payer Voluntary Refund Form (Connecticut, Indiana, Kentucky, New Jersey, and New York Providers) Overpayment Recovery Offset Request Form (Connecticut, Indiana, Kentucky and New York Providers) Overpayment Recovery Voluntary Refund Form PC-ACE Pro32—Professional Request Form (New York Providers) PC-ACE Pro32—Professional Order Form (New York Providers) Professional Provider Telecommunications Network Request Remittance Advice Request Form (Upstate NY Providers) Submitter Action Request Form (New York Providers) Provider Authorization Form    Page last modified: 11/16/2008

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