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Sample Submission Checklist for a Workers’ Compensation Medicare

This document, prepared in compliance with § 508 of the Rehabilitation Act of 1973, as amended, is intended to be used as a sample submission or checklist for a sample submission. Its publication is meant to aid submitters in organizing the information that is typically sent to CMS with a set-aside proposal. Cases using this or a similar format can generally be processed more quickly with fewer errors and development requests, resulting in faster determinations at less cost to submitters and the government.