%PDF-1.4
%
1 0 obj
<>
endobj
2 0 obj
<>stream
application/pdfMedicare Secondary Payer Change FormMedicare Secondary Payer Change FormMedicare Secondary Payer Change Form
Adobe PDF Library 7.0; modified using iTextSharp™ 5.4.3 ©2000-2013 1T3XT BVBA (AGPL-version)
2006-03-30T09:18:06-08:00Adobe InDesign CS2 (4.0.2)2014-12-21T10:12:40-08:00
endstream
endobj
3 0 obj
<>/Font<>/ProcSet[/PDF/Text]/ExtGState<>>>/Type/Page>>
endobj
12 0 obj
[/Indexed/DeviceRGB 255 13 0 R]
endobj
13 0 obj
<>stream
8;X]O>EqN@%''O_@%e@?J;%+8(9e>X=MR6S?i^YgA3=].HDXF.R$lIL@"pJ+EP(%0
b]6ajmNZn*!='OQZeQ^Y*,=]?C.B+\Ulg9dhD*"iC[;*=3`oP1[!S^)?1)IZ4dup`
E1r!/,*0[*9.aFIR2&b-C#soRZ7Dl%MLY\.?d>Mn
6%Q2oYfNRF$$+ON<+]RUJmC0InDZ4OTs0S!saG>GGKUlQ*Q?45:CI&4J'_2j$XKrcYp0n+Xl_nU*O(
l[$6Nn+Z_Nq0]s7hs]`XX1nZ8&94a\~>
endstream
endobj
14 0 obj
<>stream
8;Z]"=VcW4$q7MFm\d*r4.WU;OUtDp:CSDcl$;lP*%g7\0qaI%cJqHQNAU-CKq
/D8`c?_q]B.cd.Y)68n8pVdgX*mq9%NQ>XTSq^-%nB.D9>g)'*qp?4!MVUUETbSpA[hOG1`?eR3sf+pP!hs6lUoagA'Ak5>,%&2@`k8/UlIC6;Gg00:X
)efrtj?tV*N3jr(RD%J+orDF5fWekE'C1=E[Jr9r%VpOnmOl`OR~>
endstream
endobj
6 0 obj
<>stream
8;Z]^5n6-l$q8QLg.tf'm21_B#^JbIa1SstI.oiNl^jqUrD@`Rf?>+Tc(#
endstream
endobj
4 0 obj
<>
endobj
16 0 obj
<>
endobj
17 0 obj
<>
endobj
18 0 obj
<>
endobj
19 0 obj
<>
endobj
20 0 obj
<>/Pa5<>/Pa6<>/Pa8<>/Pa9<>/A0<>/A3<>>>
endobj
22 0 obj
[24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R 41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R 49 0 R 50 0 R 51 0 R 52 0 R 53 0 R 54 0 R 55 0 R 56 0 R 57 0 R 58 0 R 59 0 R 60 0 R 61 0 R 62 0 R 63 0 R 64 0 R 65 0 R 66 0 R 67 0 R 68 0 R 69 0 R 70 0 R 71 0 R 72 0 R 73 0 R 74 0 R 75 0 R 76 0 R 77 0 R 78 0 R 79 0 R 80 0 R 81 0 R 82 0 R 83 0 R 84 0 R 85 0 R 86 0 R 87 0 R 88 0 R 89 0 R 90 0 R 91 0 R 92 0 R 93 0 R 94 0 R 95 0 R 96 0 R 97 0 R 98 0 R 99 0 R 100 0 R 101 0 R 102 0 R 103 0 R 104 0 R 105 0 R 106 0 R 107 0 R 108 0 R 109 0 R 110 0 R 111 0 R 112 0 R 113 0 R 114 0 R 115 0 R 116 0 R 117 0 R 118 0 R 119 0 R 120 0 R 121 0 R 122 0 R 123 0 R 124 0 R 125 0 R 126 0 R 127 0 R 128 0 R 129 0 R 130 0 R 131 0 R 132 0 R 133 0 R 134 0 R 135 0 R 136 0 R 137 0 R 138 0 R 139 0 R 140 0 R 141 0 R 142 0 R 143 0 R 144 0 R 145 0 R 146 0 R 147 0 R 148 0 R 149 0 R 150 0 R 151 0 R]
endobj
23 0 obj
[null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null null 152 0 R 153 0 R 154 0 R 155 0 R 156 0 R 157 0 R 158 0 R 159 0 R 160 0 R 161 0 R 162 0 R 163 0 R 164 0 R 165 0 R 166 0 R 167 0 R 168 0 R 169 0 R 170 0 R 171 0 R 172 0 R 173 0 R 174 0 R 175 0 R 176 0 R 177 0 R 178 0 R]
endobj
152 0 obj
<>
endobj
153 0 obj
<>
endobj
154 0 obj
</C/A0/K 130/P 180 0 R/S/Span/Pg 3 0 R>>
endobj
155 0 obj
<>
endobj
156 0 obj
<>
endobj
157 0 obj
<>
endobj
158 0 obj
</C/A0/K 134/P 180 0 R/S/Span/Pg 3 0 R>>
endobj
159 0 obj
<>
endobj
160 0 obj
<>
endobj
161 0 obj
<>
endobj
162 0 obj
<>
endobj
163 0 obj
<>
endobj
164 0 obj
<>
endobj
165 0 obj
</C/A0/K 141/P 181 0 R/S/Span/Pg 3 0 R>>
endobj
166 0 obj
<>
endobj
167 0 obj
<>
endobj
168 0 obj
<>
endobj
169 0 obj
<>
endobj
170 0 obj
<>
endobj
171 0 obj
<>
endobj
172 0 obj
<>
endobj
173 0 obj
<>
endobj
174 0 obj
</C/A0/K 150/P 182 0 R/S/Span/Pg 3 0 R>>
endobj
175 0 obj
<>
endobj
176 0 obj
<>
endobj
177 0 obj
<>
endobj
178 0 obj
<>
endobj
182 0 obj
<>
endobj
183 0 obj
<>
endobj
21 0 obj
<>
endobj
151 0 obj
<>/K 127/P 21 0 R/S/Figure/Pg 15 0 R>>
endobj
187 0 obj
<>
endobj
188 0 obj
<>
endobj
189 0 obj
<>
endobj
190 0 obj
<>
endobj
191 0 obj
<>
endobj
192 0 obj
<>
endobj
193 0 obj
<>
endobj
194 0 obj
<>
endobj
195 0 obj
<>
endobj
196 0 obj
<>
endobj
197 0 obj
<>
endobj
198 0 obj
<>
endobj
199 0 obj
<>
endobj
200 0 obj
<>
endobj
201 0 obj
<>
endobj
202 0 obj
<>
endobj
203 0 obj
<>
endobj
204 0 obj
<>
endobj
205 0 obj
<>
endobj
206 0 obj
<>
endobj
207 0 obj
<>
endobj
208 0 obj
<>
endobj
209 0 obj
<>
endobj
210 0 obj
<>
endobj
211 0 obj
<>
endobj
212 0 obj
<>
endobj
213 0 obj
<>
endobj
272 0 obj
<>
endobj
273 0 obj
<>/K 90 0 R/P 213 0 R/S/Body>>
endobj
90 0 obj
<>/K 66/P 273 0 R/S/Span/Pg 15 0 R>>
endobj
89 0 obj
<>
endobj
269 0 obj
<>
endobj
270 0 obj
<>/K[102 0 R 103 0 R 104 0 R]/P 212 0 R/S/_No_paragraph_style_>>
endobj
271 0 obj
<>
endobj
105 0 obj
<>
endobj
106 0 obj
<>
endobj
107 0 obj
<>
endobj
108 0 obj
<>
endobj
102 0 obj
<>
endobj
103 0 obj
<>
endobj
104 0 obj
<>
endobj
100 0 obj
<>
endobj
101 0 obj
<>
endobj
268 0 obj
<>
endobj
149 0 obj
<>
endobj
150 0 obj
<>
endobj
267 0 obj
<>
endobj
141 0 obj
<>
endobj
142 0 obj
<>
endobj
265 0 obj
<>
endobj
266 0 obj
<>
endobj
147 0 obj
<>
endobj
148 0 obj
<>
endobj
145 0 obj
<>
endobj
146 0 obj
<>
endobj
264 0 obj
<>
endobj
143 0 obj
<>
endobj
144 0 obj
<>
endobj
263 0 obj
<>
endobj
139 0 obj
<>
endobj
140 0 obj
<>
endobj
262 0 obj
<>
endobj
138 0 obj
<>
endobj
261 0 obj
<>
endobj
137 0 obj
<>
endobj
258 0 obj
<>
endobj
259 0 obj
<>
endobj
260 0 obj
<>
endobj
135 0 obj
<>
endobj
136 0 obj
<>
endobj
130 0 obj
<>
endobj
131 0 obj
<>
endobj
132 0 obj
<>
endobj
133 0 obj
<>
endobj
134 0 obj
<>
endobj
129 0 obj
<>
endobj
257 0 obj
<>
endobj
115 0 obj
<>
endobj
116 0 obj
<>
endobj
256 0 obj
<>
endobj
127 0 obj
<>
endobj
128 0 obj
<>
endobj
254 0 obj
<>
endobj
255 0 obj
<>
endobj
125 0 obj
<>
endobj
126 0 obj
<>
endobj
123 0 obj
<>
endobj
124 0 obj
<>
endobj
253 0 obj
<>
endobj
121 0 obj
<>
endobj
122 0 obj
<>
endobj
252 0 obj
<>
endobj
119 0 obj
<>
endobj
120 0 obj
<>
endobj
251 0 obj
<>
endobj
117 0 obj
<>
endobj
118 0 obj
<>
endobj
250 0 obj
<>
endobj
113 0 obj
<>
endobj
114 0 obj
<>
endobj
248 0 obj
<>
endobj
249 0 obj
<>
endobj
111 0 obj
<>
endobj
112 0 obj
<>
endobj
109 0 obj
<>
endobj
110 0 obj
<>
endobj
247 0 obj
<>
endobj
93 0 obj
<>
endobj
94 0 obj
<>
endobj
246 0 obj
<>
endobj
97 0 obj
<>
endobj
98 0 obj
<>
endobj
245 0 obj
<>
endobj
95 0 obj
<>
endobj
96 0 obj
<>
endobj
244 0 obj
<>
endobj
91 0 obj
<>
endobj
243 0 obj
<>
endobj
92 0 obj
<>
endobj
242 0 obj
<>
endobj
99 0 obj
<>
endobj
216 0 obj
<>/K 24 0 R/P 189 0 R/S/_No_paragraph_style_>>
endobj
217 0 obj
<>/K 25 0 R/P 189 0 R/S/_No_paragraph_style_>>
endobj
218 0 obj
<>/K 26 0 R/P 189 0 R/S/_No_paragraph_style_>>
endobj
219 0 obj
<>/K 27 0 R/P 189 0 R/S/_No_paragraph_style_>>
endobj
220 0 obj
<>
endobj
221 0 obj
<>
endobj
222 0 obj
<>
endobj
223 0 obj
<>
endobj
224 0 obj
<>
endobj
225 0 obj
<>
endobj
226 0 obj
<>
endobj
227 0 obj
<>
endobj
228 0 obj
<>
endobj
229 0 obj
<>
endobj
230 0 obj
<>
endobj
231 0 obj
<>
endobj
232 0 obj
<>
endobj
233 0 obj
<>
endobj
234 0 obj
<>
endobj
235 0 obj
<>
endobj
236 0 obj
<>
endobj
237 0 obj
<>
endobj
238 0 obj
<>
endobj
239 0 obj
<>
endobj
240 0 obj
<>
endobj
241 0 obj
<>
endobj
85 0 obj
<>
endobj
80 0 obj
<>
endobj
81 0 obj
<>
endobj
82 0 obj
<>
endobj
83 0 obj
<>
endobj
84 0 obj
<>
endobj
79 0 obj
<>
endobj
78 0 obj
<>
endobj
77 0 obj
<>
endobj
76 0 obj
<>
endobj
75 0 obj
<>
endobj
69 0 obj
<>
endobj
70 0 obj
<>
endobj
71 0 obj
<>
endobj
72 0 obj
<>
endobj
73 0 obj
<>
endobj
74 0 obj
<>
endobj
63 0 obj
<>
endobj
64 0 obj
<>
endobj
65 0 obj
<>
endobj
66 0 obj
<>
endobj
67 0 obj
<>
endobj
68 0 obj
<>
endobj
57 0 obj
<>
endobj
58 0 obj
<>
endobj
59 0 obj
<>
endobj
60 0 obj
<>
endobj
61 0 obj
<>
endobj
62 0 obj
<>
endobj
51 0 obj
<>
endobj
52 0 obj
<>
endobj
53 0 obj
<>
endobj
54 0 obj
<>
endobj
55 0 obj
<>
endobj
56 0 obj
<>
endobj
50 0 obj
<>
endobj
44 0 obj
<>
endobj
45 0 obj
<>
endobj
46 0 obj
<>
endobj
47 0 obj
<>
endobj
48 0 obj
<>
endobj
49 0 obj
<>
endobj
39 0 obj
<>
endobj
40 0 obj
<>
endobj
41 0 obj
<>
endobj
42 0 obj
<>
endobj
43 0 obj
<>
endobj
37 0 obj
<>
endobj
38 0 obj
<>
endobj
35 0 obj
<>
endobj
36 0 obj
<>
endobj
33 0 obj
<>
endobj
34 0 obj
<>
endobj
31 0 obj
<>
endobj
32 0 obj
<>
endobj
30 0 obj
<>
endobj
28 0 obj
<>
endobj
29 0 obj
<>
endobj
27 0 obj
<>/K 3/P 219 0 R/S/Span/Pg 15 0 R>>
endobj
26 0 obj
<>
endobj
25 0 obj
<>
endobj
24 0 obj
<>
endobj
88 0 obj
<>
endobj
214 0 obj
<>
endobj
215 0 obj
<>
endobj
87 0 obj
<>
endobj
86 0 obj
<>
endobj
179 0 obj
<>
endobj
184 0 obj
<>
endobj
180 0 obj
<>
endobj
185 0 obj
<>
endobj
181 0 obj
<>
endobj
186 0 obj
<>
endobj
274 0 obj
<>/ViewerPreferences<>/Metadata 2 0 R/Pages 4 0 R/StructTreeRoot 16 0 R/Type/Catalog>>
endobj
15 0 obj
<>/Font<>/ProcSet[/PDF/Text]/ExtGState<>>>/Type/Page>>
endobj
8 0 obj
<>
endobj
9 0 obj
<>
endobj
276 0 obj
<>
endobj
277 0 obj
<>
endobj
286 0 obj
<>stream
H\n0l/*s&h%.vFU'
E&ʺ]F[\P^:jŲnjpͶ8zEÝ-/ю*w_eAs3'ԫeQ/ym'O;Խ;r">72tsi;C2?Iinc
C8.Kq1 $sD3 sB2'nq1gsEZ)i\>pM5j0HZ@Z}^~Z_E*ȏb?(WQ)؛"oJ1+bOFq,eeo
|Dw֍@?4ǐHE` hp
endstream
endobj
279 0 obj
<>
endobj
285 0 obj
<>
endobj
11 0 obj
<>
endobj
284 0 obj
<>stream
H\͎@