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Please send this form and all additional documentation to Fax 803 699-2432 MR-JM-A-3010 Revised 08/2015 Palmetto GBA JM Part A Medical Review MAC Mail code AG-230 P. PLEASE DO NOT USE STAPLES FOR ANY DOCUMENTATION Medical Review PWK Fax Cover Sheet ALL elds are REQUIRED. Complete one Medical Review PWK Fax Cover Sheet for each electronic claim for which documentation is being submitted. This form should not be submitted prior to ling the claim. ACN Exactly as entered in the PWK loop on the...
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