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MESA Medical & Benefits Plan 1007 Eastern Avenue Baltimore, MD 21202-4345 410-547-9111 * 800-811-MEBA (6322) * 410-659-1675(Fax) * www.mebaplans.org STATEMENT OF CLAIM FOR REIMBURSEMENT OF TRANSPORTATION
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The diag trans formpdf is a form used to report diagnostic test results.
Healthcare providers or facilities that perform diagnostic tests are required to file diag trans formpdf.
To fill out diag trans formpdf, the healthcare provider or facility must include information about the patient, the test performed, and the results obtained.
The purpose of diag trans formpdf is to ensure that diagnostic test results are properly documented and reported.
Information such as patient's name, test performed, test results, date of test, and healthcare provider's information must be reported on diag trans formpdf.
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2015 2009 MEBA Pensioner yyyy mebaplans reimbursable inpolicy sevenday 1-PCD HEREOF 800-811-MEBA III reductions REIMBURSEMENT Stepchild Coordinators reimbursed refundable ITINERARIES ROS Dependents AIRFARE applicable IRS CERTIFICATION herein computed book

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