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South University
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Mail completed forms to: Department of Labor and Industries PO Box 44269 Olympia WA 98504-4269 ✘ ✘ ✘ ✘ ✘ ✘ xxx ✘ xx F245-127-000 CMS 1500 02-2012 BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BY APPLICABLE PROGRAMS. NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. REFERS TO GOVERNMENT PROGRAMS ONLY MEDICARE AND CHAMPUS PAYME ...
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