Form CMS-1561A | Centers for Medicare & Medicaid Services

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Form #: CMS 1561A
Form Title: HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC
Revision Date: 04/01/2002
O.M.B. #: 0938-0832
O.M.B. Expiration Date: 02/28/2014
CMS Manual: N/A
Special Instructions: N/A

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CMS 1561A [PDF, 6KB]

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