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Fillable Form CMS-L564 (4-2000) - SSDC

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO.0938-0787 REQUEST FOR EMPLOYMENT INFORMATION From: Telephone No. Social Security Administration Employer’s Name and Address Date: Employee’s Name: Employee’s Social Security Number: Claimant’s Name: Claim Number: Dear Sir/Madam: We need the following information regarding...
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