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 11711 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 4500 BROAD 555-487-6789 MARY 12031918F 0711 11711 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