CMS012481 | Centers for Medicare & Medicaid Services

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Form #: CMS 10130A
Form Title: Section 1011 Provider Payment Determination
Revision Date: 01/01/2006
O.M.B. #: 0938-0952
O.M.B. Expiration Date: 01/31/2012
CMS Manual: N/A
Special Instructions: N/A

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Provider Payment Determination Form - CMS-10130A [PDF, 147KB]

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