1
Laboratory Copy - WHITE Patient Copy - YELLOW Form CMS-R-131 Exp. 03/2020 Form Approved OMB No. 0938-0566 Notifier: Professional Clinical Laboratories, LLC / 2434 Interstate Plaza Drive / Hammond, IN 46324 877-937-2190 $90.00 CMS does not discriminate in its programs and activities. To require this publication in an alternative format, please call: 1-800-MEDICARE or email: [email protected]
