Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 4/3/2007
Monthly Carrier Report On Medicare Secondary Payer Savings {CMS-1564}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
<document>DEPARTMENTOFHEALTHANDHUMANSERVICESCENTERSFORMEDICARE&MEDICAIDSERVICESCARRIERNAME10.DollarValue (Lines2+4+6+8)FORMCMS-1564(11-97)Totals 9.Number (Lines1+3+5+7)8.DollarValueUnpaid(CostAvoided) MSPClaims 1.Number REMARKS SIGNATURESpecialProjects 7.Number6.DollarValuePartialRecoveries 5.Number4.DollarValueFullRecoveries 3.Number2.DollarValueTOTAL(i)theHonorableCountyofinroom.oradjourneddate,totestifyandgiveevidenceasawitnessinthisactiononthepartofthethepartyonwhosebehalfthissubpoenawasissuedforamaximumpenaltyof$50andalldamagessustainedasaresultofyourfailuretocomply.THEPEOPLEOFTHESTATEOFNEWYORKTOCourtinBLACKLUNG&VAWORKER'SCOMP...MEDICARESECONDARYPAYERSAVINGS....(ii)Yourfailuretocomplywiththissubpoenaispunishableasacontemptofcourtandwillmakeyouliableto.Witness,HonorableMONTHLYCARRIERREPORTON......,.onthe.TITLE.County,.WORKINGAGED..NUMBER....(iii)GREETINGS: WECOMMANDYOU,thatallbusinessandexcusesbeinglaidaside,youandeachofyouattendbefore..dayof.locatedat..dayof...........ESRD.,atthe(iv).20.STATE.,.s)20..,.at...(Attorneymustsignaboveandtypenamebelow)Attorney(s)forOfficeandP.O.AddressTelephoneNo.:FacsimileNo.:E-MailAddress:.. Mobile:AUTO/NFLTTel.No.:(v)Courto'clockintheREPORTINGPERIOD(MO.&YR.),oneoftheJusticesoftheDATEDISABLEDLIABILITYnoon,andatanyrecessed(vi)AmericanLegalNet,Inc.www.USCourtForms.com(vii),</document>
Related forms
-
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/ -
Official Federal Forms/Centers For Medicare And Medicaid Services/
Form Preview
Our Products
