Form Approved OMB No. 0990-0243 Exp. Date 03/31/2014 DEPARTMENT OF HEALTH HUMAN SERVICES Office for Civil Rights OCR Civil Rights Information Request For Medicare Certification Instructions Healthcare providers applying for participation in the Medicare Part A program must receive a civil rights clearance from OCR. Complete all fields and return this form with the required polices and procedures to your State Health Department along with your other Medicare application materials. I....
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