PM 160 Claim Form Distribution
{"Image DocumentName": "PM 160 Claim Form Distribution", "Image ImageDescription": "The PM 160 is a carbonless copy form with 4 copies provided. The provider is to distribute these copies as follows: Number 1- White Copy is mailed to the Fiscal Intermediary (use the address on the bottom right hand corner of the PM 160) or managed care plan. Number 2-Yellow Copy is sent to the CHDP program in the county/city in which the service was provided. Number 3-White Copy is retained by the provider in the patient\u2019s record. Number 4-Pink Copy is given to the parent or legal guardian. 7/1/2010.", "Image XResolution": "37", "Image YResolution": "37", "Image ResolutionUnit": "Pixels/Centimeter", "Image Software": "SlidePlayer", "Image YCbCrPositioning": "Centered"}