Baltimore city non emergency number
[DOC File]LEAVE REQUEST FORM/AUTHORIZATION - United States Navy
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starts on a non-workday, the starting hour may be 0001 if not contrary to command policy. b. Block 15 - The hour for ending leave may not be later than the beginning of your normal workday if the day of return is a workday. If leave ends on a non-workday the ending hour may be 2400 if not contrary to command policy. 4.
[PDF File]Supplemental and Optional Contact Information for HUD ...
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the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
[PDF File]Consent for Release of Information
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• For non-medical information, you, the parent or the legal guardian acting on behalf of a minor child or legally incompetent adult, must sign and date this form and provide a daytime phone number. • If you are not the individual to whom the requested information pertains, state your relationship to that person. We may require
[DOC File]Aid Codes Master Chart (aid codes) - Medi-Cal
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The aid codes in this chart are meant to assist providers in identifying the types of services for which Medi-Cal and public health program recipients are eligible. The chart includes only aid codes used to bill for services through the Medi-Cal claims processing system and for other non Medi-Cal programs that
[PDF File]CMS 1763 Request for Termination of premium Hospital an/or ...
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REQUEST FOR TERMINATION OF PREMIUM HOSPITAL AND/OR SUPPLEMENTARY MEDICAL INSURANCE . ... (Number and Street, City, State and Zip Code) MAILING ADDRESS (Number and Street) 2. NAME OF WITNESS. CITY, STATE, ZIP CODE ... Baltimore, Maryland 21244-1850. Form CMS-1763 .
[PDF File]APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K ...
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The Coast Guard will not accept an application for a medical certificate without a reference number or a Merchant Mariner Credential (MMC). Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner (MP) ... City. State. Zip Code. Primary Phone Number Alternate Phone Number. E-mail Address Other ...
[PDF File]Form W-9 (Rev. October 2018)
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City, state, and ZIP code. Requester’s name and address (optional) 7. List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN).
[PDF File]Designation of Beneficiary
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Department or agency Bureau or division Location (city, state, and ZIP code) First name, middle initial, and last name of each beneficiary Social Security Number Address (Including ZIP code) Percent or fraction designated Relationship B. Information About the Beneficiary or Beneficiaries (See Back of Part 1 for examples) (type or print)
[PDF File]CM-010 Civil Case Cover Sheet
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Large number of separately represented parties Coordination with related actions pending in one or more courts in other counties, states, or countries, or in a federal court
[PDF File]CMS-460 Medicare Participating Physician or supplier agreement
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Offce Phone Number (including area code) Received by (name of carrier) Initials of Carrier Offcial . ... Medicare will still pay opt-out physicians or practitioners for emergency or urgent care services ... basis whether to provide an advance beneficiary notice of Medicare non-coverage for services in compliance
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