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PrimaryR0hQIElTIFBSSU1BUlkuIA==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 you have GHP coverage basedBBAB2552552550000000000000000000000010Arial80001117974574000000000200242008826200000000000000000000000000000000000000000000000200242008826200010000000000000000000000000000000000000000000000000010000000000000000200242008826200000000000000000000000000000000000000000002002420088263on a family member's currentBBAC2552552550000000000000000000000010Arial80001117974574000000000200242008826300000000000000000000000000000000000000000000000200242008826300010000000000000000000000000000000000000000000000000010000000000000000200242008826300000000000000000000000000000000000000000002002420088264employment, does your familyBBAD2552552550000000000000000000000010Arial80001117974574000000000200242008826400000000000000000000000000000000000000000000000200242008826400010000000000000000000000000000000000000000000000000010000000000000000200242008826400000000000000000000000000000000000000000002002420088265member's employer, thatBBAE2552552550000000000000000000000010Arial80001117974574000000000200242008826500000000000000000000000000000000000000000000000200242008826500010000000000000000000000000000000000000000000000000010000000000000000200242008826500000000000000000000000000000000000000000002002420088266sponsors or contributes to theBBAF2552552550000000000000000000000010Arial80001117974574000000000200242008826600000000000000000000000000000000000000000000000200242008826600010000000000000000000000000000000000000000000000000010000000000000000200242008826600000000000000000000000000000000000000000002002420088267GHP, employ 100 ore moreBBAG2552552550000000000000000000000010Arial80001117974574000000000200242008826700000000000000000000000000000000000000000000000200242008826700010000000000000000000000000000000000000000000000000010000000000000000200242008826700000000000000000000000000000000000000000002002420088277employees?BBAH2552552550000000000000000000000010Arial80001117974574000000000200242008827700000000000000000000000000000000000000000000000200242008827700010000000000000000000000000000000000000000000000000010000000000000000200242008827700000000000000000000000000000000000000000002002420088268No.Ny4gIElmIHlvdSBoYXZlIEdIUCBjb3ZlcmFnZSBiYXNlZCBvbiBhIGZhbWlseSBtZW1iZXIncyBj 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GHP:BBAL2122082000001010000000000000184215041000Arial800000179745740100000002002420088270000000000000000000000000000000000000000000000002002420088270014//5QAGwAZQBhAHMAZQAgAGUAbgB0AGUAcgAgAHQAaABlACAAbgBhAG0AZQAgAG8AZgAgAHQAaABl ACAARwBIAFAALgA=00100000000100000000000000000000000000000000000000010000000000000000200242008827000000000000000000000000000000000000000000002002420088271Address of GHP.BBAM2122082000001010000000000000184215041000Arial800000179745740100000002002420088271000000000000000000000000000000000000000000000002002420088271014//5QAGwAZQBhAHMAZQAgAGUAbgB0AGUAcgAgAHQAaABlACAAYQBkAGQAcgBlAHMAcwAvAGMAaQB0 AHkALwBzAHQAYQB0AGUALwB6AGkAcAAgAG8AZgAgAHQAaABlACAARwBIAFAALgA=00100000000100000000000000000000000000000000000000010000000000000000200242008827100000000000000000000000000000000000000000002002420088272Policy Identification Number:BBAN2122082000001010000000000000184215041000Arial800000179745740100000002002420088272000000000000000000000000000000000000000000000002002420088272014//5QAGwAZQBhAHMAZQAgAGUAbgB0AGUAcgAgAHQAaABlACAAUABvAGwAaQBjAHkAIABJAGQAZQBu AHQAaQBmAGkAYwBhAHQAaQBvAG4AIABOAHUAbQBiAGUAcgAgACgAdABoAGkAcwAgAG4AdQBtAGIA ZQByACAAaQBzACAAcwBvAG0AZQB0AGkAbQBlAHMAIAByAGUAZgBlAHIAcgBlAGQAIAB0AG8AIABh AHMAIAB0AGgAZQAgAGgAZQBhAGwAdABoACAAaQBuAHMAdQByAGEAbgBjAGUAIABiAGUAbgBlAGYA aQB0ACAAcABhAGMAawBhAGcAZQAgAG4AdQBtAGIAZQByACkALgA=00100000000100000000000000000000000000000000000000010000000000000000200242008827200000000000000000000000000000000000000000002002420088273Group Identification Number:BBAO2122082000001010000000000000184215041000Arial800000179745740100000002002420088273000000000000000000000000000000000000000000000002002420088273014//5QAGwAZQBhAHMAZQAgAGUAbgB0AGUAcgAgAHQAaABlACAARwByAG8AdQBwACAASQBkAGUAbgB0 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Holder/Insured:BBAQ2122082000001010000000000000184215041000Arial800000179745740100000002002420088275000000000000000000000000000000000000000000000002002420088275014//5QAGwAZQBhAHMAZQAgAGUAbgB0AGUAcgAgAHQAaABlACAAbgBhAG0AZQAgAG8AZgAgAHQAaABl ACAAcABvAGwAaQBjAHkAIABoAG8AbABkAGUAcgAvAG4AYQBtAGUAZAAgAGkAbgBzAHUAcgBlAGQA LgA=00100000000100000000000000000000000000000000000000010000000000000000200242008827500000000000000000000000000000000000000000002002420088276Relationship to Patient:BBAR2122082000001010000000000000184215041000Arial800000179745740100000002002420088276000000000000000000000000000000000000000000000002002420088276014//5QAGwAZQBhAHMAZQAgAHMAdABhAHQAZQAgAHQAaABlACAAcgBlAGwAYQB0AGkAbwBuAHMAaABp 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PrimaryR0hQIElTIFBSSU1BUlkuIA==BBBD2122082000001010000000000000184215041000Arial8000001797457401000000020024200883950000000000000000000000000000000000000000000000020024200883950116//5HAEgAUAAgAEkAUwAgAFAAUgBJAE0AUgBZAC4A00100000000100000000000000000000000000000000000000010000000000000000200242008839500000000000000000000000000000000000000000002002420088108Part VI - ESRDBDAA128128642552552550000000000000000000001Arial1400501018421504000000000200242008810800000000000000000000000000000000000000000000000200242008810800010000000000000000000000000000000000000000000000000010000000000000000200242008810800000000000000000000000000000000000000000002002420088280Do you have group healthBDAB2552552550000000000000000000000010Arial80001117974574000000000200242008828000000000000000000000000000000000000000000000000200242008828000010000000000000000000000000000000000000000000000000010000000000000000200242008828000000000000000000000000000000000000000000002002420088281plan (GHP) coverage?BDAC2552552550000000000000000000000010Arial80001117974574000000000200242008828100000000000000000000000000000000000000000000000200242008828100010000000000000000000000000000000000000000000000000010000000000000000200242008828100000000000000000000000000000000000000000002002420088285No.MS4gIERvIHlvdSBoYXZlIGdyb3VwIGhlYWx0aCBwbGFuIChHSFApIGNvdmVyYWdlPw==BDAD2122082000001010010000000000184215041000Arial80000017974574010000000200242008828500000000000000000000000000000000000000000000000200242008828500000100000000100000000100000000000000000000000000000010000000000000000200242008828500000000000000000000000000000000000000000002002420088285120024200882823200242008828522002420088284120024200882853200242008839612002420088285120024200882823200242008828522002420088284120024200882853200242008839612002420088286Yes.MS4gIERvIHlvdSBoYXZlIGdyb3VwIGhlYWx0aCBwbGFuIChHSFApIGNvdmVyYWdlPw==BDAE2122082000001010010000000000184215041000Arial80000017974574010000000200242008828600000000000000000000000000000000000000000000000200242008828600000100000000100000000100000000000000000000000000000010000000000000000200242008828600000000000000000000000000000000000000000002002420088286120024200882823200242008828622002420088283120024200882863200242008828712002420088286420024200882881200242008828652002420088289120024200882866200242008829012002420088286720024200882911200242008828682002420088292120024200882869200242008829312002420088286120024200882823200242008828622002420088283120024200882863200242008828712002420088286420024200882881200242008828652002420088289120024200882866200242008829012002420088286720024200882911200242008828682002420088292120024200882869200242008829312002420088287Name 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Number:BDAI2122082000001010000000000000184215041000Arial800000179745740100000002002420088289000000000000000000000000000000000000000000000002002420088289014//5QAGwAZQBhAHMAZQAgAGUAbgB0AGUAcgAgAHQAaABlACAAUABvAGwAaQBjAHkAIABJAGQAZQBu AHQAaQBmAGkAYwBhAHQAaQBvAG4AIABOAHUAbQBiAGUAcgAgACgAdABoAGkAcwAgAG4AdQBtAGIA ZQByACAAaQBzACAAcwBvAG0AZQB0AGkAbQBlAHMAIAByAGUAZgBlAHIAcgBlAGQAIAB0AG8AIABh AHMAIAB0AGgAZQAgAGgAZQBhAGwAdABoACAAaQBuAHMAdQByAGEAbgBjAGUAIABiAGUAbgBlAGYA aQB0ACAAcABhAGMAawBhAGcAZQAgAG4AdQBtAGIAZQByACkALgA=00100000000100000000000000000000000000000000000000010000000000000000200242008828900000000000000000000000000000000000000000002002420088290Group Identification Number:BDAJ2122082000001010000000000000184215041000Arial800000179745740100000002002420088290000000000000000000000000000000000000000000000002002420088290014//5QAGwAZQBhAHMAZQAgAGUAbgB0AGUAcgAgAHQAaABlACAARwByAG8AdQBwACAASQBkAGUAbgB0 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VIBDBA2122082000001010000000000000184215041000Arial80000017974574010000000200242008828200000000000000000000000000000000000000000000000200242008828200000100000000000100000000000000000000000000000000000010000000000000000200242008828200000000000000000000000000000000000000000002002420088284No.BDBB02552550000010000000000000184215040000Arial80000017974574010000000200242008828400000000000000000000000000000000000000000000000200242008828400000000000000100000000000000000000000000000000000000010000000000000000200242008828400000000000000000000000000000000000000000002002420088283Yes.BDBC02552550000010000000000000184215040000Arial80000017974574010000000200242008828300000000000000000000000000000000000000000000000200242008828300000000000000100000000000000000000000000000000000000010000000000000000200242008828300000000000000000000000000000000000000000002002420088396Medicare is 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of Transplant:BGAF2122082000001010000000000000184215041000Arial800000179745740100000002002420088322000000000000000000000000000000000000000000000002002420088322012//5EAGEAdABlACAAbwBmACAAdAByAGEAbgBzAHAAbABhAG4AdAAuAA==001000000001000000000000000000000000000000000000016777216010000000000000000200242008832200000000000000000000000000000000000000000002002420088320No.BGBA02552550000010000000000000184215040000Arial80000017974574010000000200242008832000000000000000000000000000000000000000000000000200242008832000000000000000100000000000000000000000000000000000000010000000000000000200242008832000000000000000000000000000000000000000000002002420088321Yes.BGBB02552550000010000000000000184215040000Arial80000017974574010000000200242008832100000000000000000000000000000000000000000000000200242008832100000000000000100000000000000000000000000000000000000010000000000000000200242008832100000000000000000000000000000000000000000002002420088315BHAA128128642552552550000000000000000000001Arial1400501018421504000000000200242008831500000000000000000000000000000000000000000000000200242008831500010000000000000000000000000000000000000000000000000010000000000000000200242008831500000000000000000000000000000000000000000002002420088323Have 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is PrimaryTUVESUNBUkUgSVMgUFJJTUFSWS4gBIBC2122082000001010000000000000184215041000Arial8000001797457401000000020024200883970000000000000000000000000000000000000000000000020024200883970116//5TAFQATwBQAC4AIAAgAE0ARQBEAEkAQwBBAFIARQAgAEkAUwAgAFAAUgBJAE0AQQBSAFkALgA= 00100000000100000000000000000000000000000000000000010000000000000000200242008839700000000000000000000000000000000000000000002002420088344BJAA128128642552552550000000000000000000001Arial1400501018421504000000000200242008834400000000000000000000000000000000000000000000000200242008834400010000000000000000000000000000000000000000000000000010000000000000000200242008834400000000000000000000000000000000000000000002002420088345Are you entitled to MedicareBJAB2552552550000000000000000000000010Arial80001117974574000000000200242008834500000000000000000000000000000000000000000000000200242008834500010000000000000000000000000000000000000000000000000010000000000000000200242008834500000000000000000000000000000000000000000002002420088346on the 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your initial entitlementBKAB2552552550000000000000000000000010Arial80001117974574000000000200242008835400000000000000000000000000000000000000000000000200242008835400010000000000000000000000000000000000000000000000000010000000000000000200242008835400000000000000000000000000000000000000000002002420088355to Medicare (includingBKAC2552552550000000000000000000000010Arial80001117974574000000000200242008835500000000000000000000000000000000000000000000000200242008835500010000000000000000000000000000000000000000000000000010000000000000000200242008835500000000000000000000000000000000000000000002002420088356simultaneous or dualBKAD2552552550000000000000000000000010Arial80001117974574000000000200242008835600000000000000000000000000000000000000000000000200242008835600010000000000000000000000000000000000000000000000000010000000000000000200242008835600000000000000000000000000000000000000000002002420088357entitlement) based on 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Continues to PayR0hQIENPTlRJTlVFUyBUTyBQQVkgUFJJTUFSWSBEVVJJTkcgVEhFIDMwLU1PTlRIIENPT1JESU5B VElPTiBQRVJJT0QuBKBC2122082000001010000000000000184215041000Arial8000001797457401000000020024200883980000000000000000000000000000000000000000000000020024200883980116//5TAFQATwBQAC4AIAAgAEcASABQACAAQwBPAE4AVABJAE4AVQBFAFMAIABUAE8AIABQAEEAWQAg AFAAUgBJAE0AQQBSAFkAIABEAFUAUgBJAE4ARwAgAFQASABFACAAMwAwAC0ATQBPAE4AVABIACAA QwBPAE8AUgBEAEkATgBBAFQASQBPAE4AIABQAEUAUgBJAE8ARAAuAA==00100000000100000000000000000000000000000000000000010000000000000000200242008839800000000000000000000000000000000000000000002002420088366BLAA128128642552552550000000000000000000001Arial1400501018421504000000000200242008836600000000000000000000000000000000000000000000000200242008836600010000000000000000000000000000000000000000000000000010000000000000000200242008836600000000000000000000000000000000000000000002002420088362Does the working aged orBLAB2552552550000000000000000000000010Arial80001117974574000000000200242008836200000000000000000000000000000000000000000000000200242008836200010000000000000000000000000000000000000000000000000010000000000000000200242008836200000000000000000000000000000000000000000002002420088363disability MSP provision applyBLAC2552552550000000000000000000000010Arial80001117974574000000000200242008836300000000000000000000000000000000000000000000000200242008836300010000000000000000000000000000000000000000000000000010000000000000000200242008836300000000000000000000000000000000000000000002002420088364(i.e., is the GHP alreadyBLAD2552552550000000000000000000000010Arial80001117974574000000000200242008836400000000000000000000000000000000000000000000000200242008836400010000000000000000000000000000000000000000000000000010000000000000000200242008836400000000000000000000000000000000000000000002002420088365primary based on age orBLAE2552552550000000000000000000000010Arial80001117974574000000000200242008836500000000000000000000000000000000000000000000000200242008836500010000000000000000000000000000000000000000000000000010000000000000000200242008836500000000000000000000000000000000000000000002002420088367disability entitlement)?BLAF2552552550000000000000000000000010Arial80001117974574000000000200242008836700000000000000000000000000000000000000000000000200242008836700010000000000000000000000000000000000000000000000000010000000000000000200242008836700000000000000000000000000000000000000000002002420088368No.Ny4gIERvZXMgdGhlIHdvcmtpbmcgYWdlZCBvciBkaXNhYmlsaXR5IE1TUCBwcm92aXNpb24gYXBw bHkgKGkuZS4sIGlzIHRoZSBHSFAgYWxyZWFkeSBwcmltYXJ5IGJhc2VkIG9uIGFnZSBvciBkaXNh YmlsaXR5IGVudGl0bGVtZW50KT8=BLAG2122082000001010010000000000184215041000Arial800000179745740100000002002420088368000000000000000000000000000000000000000000000002002420088368000001000000001001000001000000000000000000000000000000100000000000000002002420088368000000000000000000000000000000000000000000020024200883681200242008837012002420088368220024200884001200242008836812002420088370120024200883682200242008840012002420088369Yes.Ny4gIERvZXMgdGhlIHdvcmtpbmcgYWdlZCBvciBkaXNhYmlsaXR5IE1TUCBwcm92aXNpb24gYXBw bHkgKGkuZS4sIGlzIHRoZSBHSFAgYWxyZWFkeSBwcmltYXJ5IGJhc2VkIG9uIGFnZSBvciBkaXNh 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Continues to PayR0hQIENPTlRJTlVFUyBUTyBQQVkgUFJJTUFSWSBEVVJJTkcgVEhFIDMwLU1PTlRIIENPT1JESU5B VElPTiBQRVJJT0QuBLBC2122082000001010000000000000184215041000Arial8000001797457401000000020024200883990000000000000000000000000000000000000000000000020024200883990116//5HAEgAUAAgAEMATwBOAFQASQBOAFUARQBTACAAVABPACAAUABBAFkAIABQAFIASQBNAEEAUgBZ ACAARABVAFIASQBOAEcAIABUAEgARQAgADMAMAAtAE0ATwBOAFQASAAgAEMATwBPAFIARABJAE4A QQBUAEkATwBOACAAUABFAFIASQBPAEQALgA=00100000000100000000000000000000000000000000000000010000000000000000200242008839900000000000000000000000000000000000000000002002420088400Medicare continues to PayTUVESUNBUkUgQ09OVElOVUVTIFRPIFBBWSBQUklNQVJZLg==BLBD2122082000001010000000000000184215041000Arial8000001797457401000000020024200884000000000000000000000000000000000000000000000000020024200884000116//5NAEUARABJAEMAQQBSAEUAIABDAE8ATgBUAEkATgBVAEUAUwAgAFQATwAgAFAAQQBZACAAUABS 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no MSP data is found inBNAC2552552550000000000000000000000010Arial80001117974574000000000200242008837500000000000000000000000000000000000000000000000200242008837500010000000000000000000000000000000000000000000000000010000000000000000200242008837500000000000000000000000000000000000000000002002420088376the Common Working File (CWF)BNAD2552552550000000000000000000000010Arial80001117974574000000000200242008837600000000000000000000000000000000000000000000000200242008837600010000000000000000000000000000000000000000000000000010000000000000000200242008837600000000000000000000000000000000000000000002002420088377for the beneficiary, theBNAE2552552550000000000000000000000010Arial80001117974574000000000200242008837700000000000000000000000000000000000000000000000200242008837700010000000000000000000000000000000000000000000000000010000000000000000200242008837700000000000000000000000000000000000000000002002420088378provider still asks the typesBNAF2552552550000000000000000000000010Arial80001117974574000000000200242008837800000000000000000000000000000000000000000000000200242008837800010000000000000000000000000000000000000000000000000010000000000000000200242008837800000000000000000000000000000000000000000002002420088379of questions stated andBNAG2552552550000000000000000000000010Arial80001117974574000000000200242008837900000000000000000000000000000000000000000000000200242008837900010000000000000000000000000000000000000000000000000010000000000000000200242008837900000000000000000000000000000000000000000002002420088380provides any MSP informationBNAH2552552550000000000000000000000010Arial80001117974574000000000200242008838000000000000000000000000000000000000000000000000200242008838000010000000000000000000000000000000000000000000000000010000000000000000200242008838000000000000000000000000000000000000000000002002420088381on the bill using the properBNAI2552552550000000000000000000000010Arial80001117974574000000000200242008838100000000000000000000000000000000000000000000000200242008838100010000000000000000000000000000000000000000000000000010000000000000000200242008838100000000000000000000000000000000000000000002002420088382uniform billing codes.BNAJ2552552550000000000000000000000010Arial80001117974574000000000200242008838200000000000000000000000000000000000000000000000200242008838200010000000000000000000000000000000000000000000000000010000000000000000200242008838200000000000000000000000000000000000000000002002420088383This information will then beBNAK2552552550000000000000000000000010Arial80001117974574000000000200242008838300000000000000000000000000000000000000000000000200242008838300010000000000000000000000000000000000000000000000000010000000000000000200242008838300000000000000000000000000000000000000000002002420088384used to update CWF throughBNAL2552552550000000000000000000000010Arial80001117974574000000000200242008838400000000000000000000000000000000000000000000000200242008838400010000000000000000000000000000000000000000000000000010000000000000000200242008838400000000000000000000000000000000000000000002002420088385the billing process.BNAM2552552550000000000000000000000010Arial80001117974574000000000200242008838500000000000000000000000000000000000000000000000200242008838500010000000000000000000000000000000000000000000000000010000000000000000200242008838500000000000000000000000000000000000000000002002420088386BOAA128128642552552550000000000000000000001Arial1400501018421504000000000200242008838600000000000000000000000000000000000000000000000200242008838600010000000000000000000000000000000000000000000000000010000000000000000200242008838600000000000000000000000000000000000000000002002420088387BPAA128128642552552550000000000000000000001Arial1400501018421504000000000200242008838700000000000000000000000000000000000000000000000200242008838700010000000000000000000000000000000000000000000000000010000000000000000200242008838700000000000000000000000000000000000000000002002420088389^ Print MSPBPAB22422417500010000000000000001105251021000Arial800000184215040000000002002420088389000000000000000000000000000000020000000000000110111000000000000000000000000000000002002420088389000000000000000000000000000000020000000000000110111000000000000000000000000000000002002420088389000000000000000000000000000000000000000000000002002420088389000101000000000001100000000000000000000000000000000065537000000000000000000200242008838900000000000000000000000000000000000000000002002420088389225744200020000020024200883891202002420088MSP 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20024AR20013416501Arial1010

4049Medicare MSP 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Label105368709111Arial00141000.3019999861717221.572999954223630.4790000021457675.3540000915527300000000000000000000000000000000000000000000000000000000TUVESUNBUkUgU0VDT05EQVJZIFBBWUVSIChNU1ApIFFVRVNUSU9OTkFJUkU=0000000000000Arial001011677721500000000000000000025500000000000000040492Report Label40167772150Arial00100008.81200027465820.51.207999944686897.50000000000000300011000001000000000000000000001000100000126322560000000000000Arial0010116777215000000001000000286261248000000000000000000404911Date74167772150Arial00101000.2189999967813490.50.7599999904632570.676999986171722000000000000000000000000000000000000000000000000000000000000000000000Arial0010116777215000000000000000001255000000000000000404912Last, 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