Medicare Secondary Payer Statement Of Employer In Support Of Application For Small Employer Exception Page 2

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MSP Cover Letter
Instructions:
Please copy the next page onto your letterhead, date and sign it, then return it,
along with the completed Medicare Secondary Payer Statement of Employer
form (previous page) to Banyan Administrators, LLC, via:
• Toll-free FAX:
(877) 237-4519
<OR>
• Scan and email:
If you have any questions, please call our toll free number (877) 480-7923 to
speak with a Banyan Administrators, LLC call center representative.

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