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CMS Manual SystemDepartment of Health & Human Services (HHS)Pub 10004 Medicare Claims ProcessingCenters for Medicare & Medicaid Services (CMS)Transmittal 11722Date: December 2, 2022Change Request
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01
Obtain a CR 12903-CMS form from the CMS website or your healthcare provider.
02
Fill in your personal information such as name, address, and contact details.
03
Provide details about the medical services or supplies received.
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Include information about the healthcare provider and their billing details.
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Sign and date the form before submitting it to the relevant authority.

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01
Individuals who have received medical services or supplies and need to file a claim with CMS for reimbursement.
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