X 4 3x 2x 2 7

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X 4 3x 2x 2 7

X 4 3x 2x 2 7

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X 4 3x 2x 2 7INSTRUCTIONS FOR COMPLETING THE FORM: A brief description of each data ... Column B: enter the correct CMS/OWCP standard "place of service" (POS) code ... PLEASE PRINT OR TYPE FORM HCFA 1500 12 90 FORM RRB 1500 FORM OWCP 1500 APPROVED OMB 0938 0008 Page 2 BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT

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CMS 1500

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