Request for Medicaid Payment Information / Copy of Paid Claims Paid by Medicaid - Alabama
Request for Re-review of Medicare Claims Related to the Settlement Agreement in Ryan V. Price
Form B Request to Amend Protected Health Information - Alabama
Form 404 Request for Administrative Review of Outdated Medicaid Claim - Alabama
Pedido De Pago De Informacion De Medicaid/Copia De Reclamo De Pago De Medicaid - Alabama (Spanish)
DD Form 2871 Request to Restrict Medical or Dental Information
DA Form 4254 Request for Private Medical Information
DA Form 4876 Request and Release of Medical Information to Communications Media
Form IHS-917 Request for Correction/Amendment of Protected Health Information
Form HCFA-605 Request for Approval as a Hospital Provider of Extended Care Services (Swing-Bed) in the Medicare and Medicaid Programs
Form PHS-6300-1 Medical Special Pay (Msp) Contract Request
VA Form 10-5345 Request for and Authorization to Release Health Information
VA Form 10-0485 Request for and Authorization to Release Protected Health Information to Health Information Exchanges
VA Form 10-10163 Request for and Permission to Participate in Sharing Protected Health Information Through Health Information Exchanges
DD Form 2642 CHAMPUS Claim Patient's Request for Medical Payment
VA Form 10-0527-CHOICE Request and Authorization to Release Protected Health Information to the Choice Program
Form CMS-1490S Patient's Request for Medical Payment
VA Form 10-5345A Individuals' Request for a Copy of Their Own Health Information
VA Form 10-5345a-mhv Individuals' Request for a Copy of Their Own Health Information
Form HUD-1044-D Multifamily Insurance Benefit Claim - Payment Information in Support of Claim
GSA Form 2578 Report of Investigation of Claim for Waiver of Erroneous Payment of Pay and Allowances
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