- Form #
- CMS 2384
- Form Title
- THIRD PARTY PREMIUM BILLING REQUEST, MEDICARE
- Revision Date
- 11/01/2003
- O.M.B. #
- 0938-0041
- O.M.B. Expiration Date
- 11/30/2006
- CMS Manual
- N/A
- Special Instructions
- You must either visit or contact the Social Security Administration to obtain this form. 1-800-772-1213
