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EXAMPLE OR NER ITIO ACT L PR 1 2 3 4 5 ERA GEN 1 2 / 0 2 / 0 6 X d If the service is one of the pre-printed services place an X as indicated on the form* space provided* 5. Patient MUST sign the form AFTER the form has been completed* 6. Send the RED copy to Medicare keep the BLACK copy for your records and give the GREEN copy to the patient. Designed 03/06 PRIVACY NOTE The information provided will be used to assess any Medicare benefit payable for the services rendered and to facilitate the p ...

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