Designed for those facilities whose Medicare intermediaries require that only information applicable to the specific situation appears on the denial notice. This form allows for space for the appropriate denial reason to be handwritten or typed. Applicable denial reasons are conveniently printed on the back of part three for easy reference and visiblity while completing the form.
8 1/2" x 14" (legal size), 3-part carbonless snap set, white original, color coded copies, black ink, wrapped in 50s
