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PLATFORM CMS2552104012.7 (Cont.)EXHIBIT 3B CHARITY CARE LISTING PROVIDER NAME:CCN:CHARITY CARE FOR (SELECT ONE):UNINSURED PATIENTS INSURED PATIENTS#NONCOM. CGS COV. BY MEDICAID 14Rev. PATIENT CLAIM
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Healthcare providers and facilities that are required to report their financial information to Medicare may need to fill out the 4012 form cms-2552-10 12-22.
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