TN 4 (08-03)

GN 03501.046 Sample Transmittal Flag

 

EXHIBIT 1

Transmittal Flag

 

 

 

Transmittal Flag

 

AR Readjudication Request

 

TO:     DDS/OHA address and routing code

 

FROM:    FO address and routing code

 

LEVEL OF LAST DETERMINATION (CHECK ONE BLOCK)

 

[ ] INITIAL  [ ]  RECONSIDERATION   [ ] OHA LEVEL

 

CLAIM NUMBER

 

NAME