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Fill out section a and take the form to your employer. You can complete the part b sep online or.

This Form Is Used To Prove Your Group Health Care Coverage Based On Current Employment.

Download and print this form to prove your group health care coverage based on current. You can use this form to. You need to get the completed form from your employer and include it with your application for. You can complete the part b sep online or you can mail your completed cms.

Department Of Health And Human Services.

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Fill Out Section A And Take The Form To Your Employer.

This form is your application for medicare part b (medical insurance).