Attorney Authorization Form

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Please use black ink and capital letters to ﬁll in am1ab the boxes. §1395y(b)(2) and § 1862(b)(2)(a)/section and § 1862(b)(2)(a)(ii) of the social security act, medicare may not pay for a beneficiary's medical expenses when payment “has been made or can reasonably be expected to be made under a workers’ compensation plan, an automobile or liability insurance policy or plan..

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Detailed requirements and instructions are on page 2 of this form. Web by law, 42 u.s.c. Check all that apply i am under the age of 18. Certificate of good standing (district court) attorney forms :

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City state zip code + 4 §1395y(b)(2) and § 1862(b)(2)(a)/section and § 1862(b)(2)(a)(ii) of the social security act, medicare may not pay for a beneficiary's medical expenses when payment “has been made or can reasonably be expected to be made under a workers’ compensation plan, an automobile or liability insurance policy or plan. Web form number form name category ; Web by submitting this completed, signed, and dated form, i authorize and request the office of the attorney general (oag) to do the following:

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Information you omit or print outside of the boxes will delay processing. Power of attorney revocation form. Web power of attorney authorization use this form to grant authorization to an individual to sign on your behalf. Please use black ink and capital letters to ﬁll in am1ab the boxes.

(You Must Place Your Initials Next To Each Item That Applies.) Release Information Or Records On My Case (Oag Number Given Above) Initials:________ This Person Is (Check One) Y

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