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Question: View the CMS1450 form for Mary Torre posted Check the following blocks for mistakes Is the bloc…

4500 BROAD 555-487-6789 MARY 12031918F 0711 11。711 TORRE MARY J 452 JEME STREET 01 650 210 ROOM AND 1600.00 4800.00 270 MED-S

  1. View the CMS1450 form for Mary Torre posted
  2. Check the following blocks for mistakes
  • Is the block filled in with information or are they blank?
  • Is the block required or not required?
  1. FL61
  2. FL44
  3. FL45
  4. FL55
  5. FL74
  6. FL74a-e
4500 BROAD 555-487-6789 MARY 12031918F 0711 11。711 TORRE MARY J 452 JEME STREET 01 650 210 ROOM AND 1600.00 4800.00 270 MED-SUR SUPPLIES 31 700:50 99:50 159 00 196.00 700.00 15171 50 450 : EMERGENCY ROOM SERVICE 001 TOTAL PAGE OF CREATION DATE TOTALS MEDPRIME-HPR TORRE MARY 011 15462689710 RETIRED 080184 E8497 90 I CARD PERRY