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Page 1:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 2:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 3:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 4:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 5:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 6:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 7:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 8:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 9:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 10:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 11:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 12:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number
Page 13:  · payment is called an Authorization Agreement for Direct Payment. ... letter from the Social Security Administration ... SAMPLE ONLY Name: Medicare Claim Number

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