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cms l564
cms l564

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

Description

You may call at the above telephone number if you have any questions. Sincerely Office Manager 1. Is or was the claimant covered under an Employer Group Health Plan Yes No 2. If yes give the original date the coverage began. mm/yyyy 3. Has the coverage ended 5. When did the employee work for your company From Signature and Title of Company Official To Still Employed Telephone Number According to the Paperwork...
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