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HEALTH INSURANCE CLAIM FORM

PA

1
2 3 a
MI
DATES

84
NUCC Institution
- MAX
PLEASE PRINT OR TYPE
CAND-0906
1000
17

TFP - ComplyRight CMS-1500 Health Insurance Claim Forms (02/12), 8-1/2" x 11", Pack of 500 (CMS12LC500) - White/Red

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IMPORTANT TAX RETURN DOCUMENT ENCLOSED

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OW3

ComplyRight - Self Seal Security Tinted Double-Window Tax Envelopes, 50/Pack (3333250) - White

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HEALTH INSURANCE CLAIM FORM

PA

1
2 3 a
MI
DATES

84
NUCC Institution
- MAX
PLEASE PRINT OR TYPE
CAND-0906
1000
17

ComplyRight - CMS-1500 Health Insurance Claims, 2500/Pack (CMS12LC) - White/Red

Not yet reviewed

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1969 1096
Annual Summary and Transmittal of U.S. Information Returns
2026
For Official Use Only

First, this entire page to the Internal Revenue Service Bend IN's New with ? " Per forms checked
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