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cms l564
cms l564

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

Description

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 Social Security Number Claimant s Name Claim Number Dear Sir/Madam We need the following information regarding the above claimant. You may call at the above telephone number ...
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