beneficiary proof of representation form

If you do not represent the beneficiary but want to request, that you will understand what a consent to release document is as, Pursuant to the Privacy Act, Medicare does not release information, from a beneficiarys records without appropriate authorization to do, For beneficiaries who have filed a claim for liability insurance (including, either a proof of representation document signed by the beneficiary and the beneficiarys representative or a consent to release, workers compensation carriers without a consent to release, individual or entity (including an attorney) to act on the beneficiarys. In contrast, a TOD designation transfers the ownership of an asset to the designated beneficiary. Beneficiary non-attorney representatives. Liability Insurance (Including Self-Insurance). PDF. model language for proof of representation and consent to release for purposes of interacting. Irrevocable trusts in New York Get your online template and fill it in using progressive features. Probate in New York Address: See attached. endstream endobj 364 0 obj <>/Metadata 48 0 R/OCProperties<>/OCGs[378 0 R 379 0 R]>>/PageLayout/SinglePage/Pages 359 0 R/StructTreeRoot 82 0 R/Type/Catalog/ViewerPreferences<>>> endobj 365 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 366 0 obj <>stream Living Trust Enjoy smart fillable fields and interactivity. information in the Rights and Responsibilities Letter and Rights and Responsibilities Brochure which explain what documentation is needed or go directly to the information provided in the Proof of Representation Model Language document. Under these circumstances, the exchange of information is a one- way street. ESTATE Model Language . Will Attorney Where to Submit Proof of Representation: Liability Insurance, No-Fault Insurance, Workers' Compensation: NGHP . This does NOT mean a spouse or other heir/representative: Please complete numbers 1-4 below only: 1. Beneficiary Name (please print exactly as shown on your Medicare card): _____ Medicare Number (as shown . This is also a requirement when requesting funds from various financial institutions and the standard procedure is for the beneficiary to provide an original or certified copy of their proof of ID and proof of address. will and trust Please visit https://go.cms.gov/cobro for further instructions. best estate planning lawyer in Long Island, The Top Reasons to Hire a Retirement Planning Attorney in NYC. submit both the necessary proof of representation document or retainer agreement from the beneficiarys representative and the documentation required from representative payees, conservators, guardians, power of attorney. Irrevocable trusts Estate Planning Attorneys ) The people who directly inherit the assets are called primary beneficiaries. Try it out yourself! If there is no will or formal estate, the document or documents must be signed by an individual who is entitled under state law to pursue the applicable claim. Beneficiary attorneys may also provide the same proof of representation as non-attorneys if they wish to do so. HOW TO APPLY FOR MEDICARE BENEFICIARY PROOF OF REPRESENTATION Submitting the necessary documents for Proof of Representation is a straightforward process. If your settings prevent this, you may also copy and paste join-masshealth-member-forms@listserv.state.ma.us into your e-mail address line. representative payee for the Medicare beneficiary, and the MSPRC will verify this status within CMS systems. #1 Internet-trusted security seal. If you do not represent the beneficiary but want to request. They also try to hide their actions from the beneficiaries (whom are often relatives). Notice of nondiscrimination Model Language for Proof of Representation or. Execute your docs in minutes using our simple step-by-step guide: Swiftly produce a MSPRC Proof of Representation without needing to involve professionals. If you represent the beneficiary, please read this document so that you understand what you need for proper proof of representation (vs. the ability to only receive certain information through a "consent Agents must have a beneficiary specific statement (including the beneficiarys name and HICN) on the insurer or workers compensation entitys letterhead that the agent is representing the insurer or workers compensation carrier with respect to a claim involving the identified Medicare beneficiary. ) Queens Probate Lawyer They can override the information provided by you. Agents for insurers or workers compensation carriers. Coronavirus There are already more than 3 million users taking advantage of our unique catalogue of legal forms. Will Lawyers, Copyright 2022 - All Rights Reserved SiteMapTags. Copyright 2006 forms in Word www Forms in Word com For individual Clinic Use only the name of the clinic address here Pet name, species and breed of dog Cat or other Breed Color sex ". Specify the following information for the representative: name, type of representative, firm/company name (if applicable), address, telephone number. Save the beneficiary receipt of distribution, print, or email it. Will Lawyer in Queens This is a right that many people take for granted, and it is one that should be exercised. (This includes any attempt to request such information through a Freedom of Information Act (FOIA) request. Kcez.+/'BSIrzZyU8TB1O97z%1;bS;{pV$k0Kfx4(? C. estate planning lawyers in Brooklyn Ensures that a website is free of malware attacks. One of the most difficult parts of beneficiary representation is that we are working with people who are being taken advantage of during one of the most painful and vulnerable moments of their life. ) Estate Planning Attorney in NYC Estate Planning 101 ) Beneficiary designation form is used when you want to designate the people who will inherit the assets. best estate planning lawyer in Manhattan Use expert-generated web templates and video instructions that direct you through the entire process from start to finish. Retirement Planning Attorney The individual or entity may provide necessary. Estate Planning Lawyer Brooklyn Estate Planning Attorney Brooklyn Probate Lawyer Brooklyn Probate Attorney Brooklyn Estate Planning Lawyer NYC Estate Planning Brooklyn Probate Attorney Brooklyn Probate Attorney Long Island Estate Planning Attorney Long Island Queens Estate lawyer New York Probate Lawyer Brooklyn Estate Planning Attorney Brooklyn Probate Lawyer, ASSESTS Decide on what kind of signature to create. ______________. update your living trust The retainer agreement is on attorney letterhead or accompanied by a cover note on letterhead. Will Attorney NYC Beneficiary's Name Please print exactly as shown on your Medicare card: 2. If you have been named as a beneficiary of the estate or trust of a loved one, you may be looking forward to getting the items or money that you are due. Before you designate your beneficiaries, you should reconsider every person because they will become active as soon as you will retire from the job. The retainer agreement is signed by the beneficiary, The beneficiarys name and Medicare Health Insurance Claim. Retirement Planning Beneficiary attorney representatives may submit their retainer. We use cookies to improve security, personalize the user experience, enhance our marketing activities (including cooperating with our marketing partners) and for other business use. The common beneficiaries are a wife, children and other relatives of the person. Estate Planning Attorney NYC At the end of the form, there should be a space for the signatures of benefited. In order to designate, you are required to provide the names of people you want to be your beneficiary as well as the percentage amount of assets they will get. Get the MSPRC Proof of Representation you need. attorney must have a letter from the first attorney showing his/her association on the beneficiarys claim and the necessary proof of representation document or retainer agreement from the beneficiary to the first attorney. The Top Reasons to Hire a Retirement Planning Attorney in NYC Provide his/her Medicare Health Insurance Claim Number (HICN)(the number on the Medicare card). Join us right now and gain access to the top library of browser-based blanks. Probate Lawyer Retirement Planning Lawyers in Queens filing an appeal (if appropriate) when that beneficiary is involved in a liability, workers compensation, or auto/no-fault situation. Complete the empty areas; involved parties names, addresses and numbers etc. named Medicare beneficiary for the purpose of resolving any Medicare Secondary Payer conditional payments, demands, compromises, waivers and appeals related to the date of illness/injury listed . Follow this simple guideline edit P ROOF OF REPRESENTATION Authorized Representative in PDF format online at no cost: Sign up and sign in. Whether you are in an active conflict with an executor, or you just want to make sure that everything is done right, you need to get legal representation as quickly as possible. Kk-BQ#7j2}HlO{o[ZKUtaYEWY)sCA8{g+9-U&68NCxk\R!Mc#8 eBsNN estate planning lawyers in Long Island eHnh)U0q62+l9fL^0iqP g' Best Estate Planning in Brooklyn Probate Lawyer in Brooklyn Change the blanks with exclusive fillable areas. Just press the button directly below and experience the advantages of choosing our PDF editor with handy features in the toolbar. Conservator* Guarantees that a business meets BBB accreditation standards in the US and Canada. P.O. Retirement Planning Lawyers Queens For beneficiaries who have filed a claim for liability insurance (including self-insurance), no-fault insurance, or workers, compensation, this typically means that the MSPRC will receive either a proof of representation document signed by the beneficiary and the beneficiarys representative or a consent to release document signed by the beneficiary. Proof of Representation vs. Consent to Release. best estate planning lawyer in Long Island You can decide how often to receive updates. The best way to designate them is to use the beneficiary designation form. Once you have completed the request, please email a saved copy to SubrogationReferrals@Humana.com, or mail to: Humana Subrogation and Other payer Liability 004/48120 P.O. Include the particular date and place your e-signature. Size 44.6 Kb |Download, Copyright 2015-2018 All rights reserved. Coronavirus and Estate Planning US Legal Forms allows you to quickly create legally-compliant documents based on pre-built web-based blanks. The representative must sign and date the document to show that he/she has agreed to represent the beneficiary. Representative Payee Notify the MSPRC if you are the. Once the BCRC has the appropriate documentation, it can communicate with the attorney and act upon requests made by the attorney on behalf of the beneficiary. Probate Attorney These are some facts you may want to analyze before starting dealing with the proof of representation. Estate planning lawyers in New York His model language also makes provisions for the information your representative must provide. Follow the simple instructions below: Finding a authorized professional, making a scheduled appointment and going to the office for a private meeting makes doing a MSPRC Proof of Representation from start to finish exhausting. Asset Protection Your attorney may have the forms on hand, or you can download them from Medicare. Retirement Planning Lawyers 2010-09-29. Situations where the beneficiarys representative (representative payee, conservator, guardian, power of attorney) has hired an attorney or the beneficiary attorney has referred the case to another attorney. USLegal received the following as compared to 9 other form sites. This form can be used to verify that you are authorized to vote in a particular election. compensation settlement, judgment, award, or other payment, new proof of representation on behalf of the beneficiarys estate must be submitted. Unfortunately, this does not always happen as it should. Under these circumstances, the exchange of information is a two way street. estate planning lawyer in New York Title. Retirement Planning Lawyer Proof of Representation Individual other than an Attorney: Attorney Guardian Conservator Power of Attorney Name: Relationship to the Beneficiary: Firm or Company Name: Address: Address Line 2: City/State/ZIP: Telephone Medicare Beneficiary Information and Signature/Date Beneficiary's Name (please print exactly as shown on your Medicare card): One of our cases that we recently worked on involved a beneficiary who lives abroad and due to their age, they are in a . The form you are looking for is not available online. Since the process of designating the beneficiaries is an important process that should be done with great care, there should be a separate column in the form where you will have to provide the names of primary beneficiaries. Will Lawyer in Brooklyn Box 2257 Louisville, KY 40201-2257 If you have additional questions or need to supply additional information, please contact us. Asset Protection Lawyer ) All rights reserved. beneficiarys attorney has referred the case to another attorney, Beneficiarys representative has hired an attorney, agreement from the beneficiarys representative, Beneficiary attorney refers a matter to another attorney, If a beneficiary is deceased before resolution of a Medicare, proof of representation on behalf of the beneficiarys estate must be. Will Lawyer Queens Individual other than an Attorney: Asset Protection Attorney Probate New York documents on www.msprc.info which provide model language for proof of representation and consent to release for purposes of interacting with the MSPRC. ( Rate template 4.8 Satisfied 48 votes Probate Lawyers ( There are several reasons why you may need to provide proof of representation, including: voting from outside your home state, voting in a presidential election as a delegate, or voting as an absentee voter. Complete the Receipt and Release Personal Representative of the Form and Sign it Electronically How it works Select the receipt and release form and open it. Estate planning in Manhattan Please refer to the PowerPoint document on this website titled: Rules and Model MSPRC.info Changes in process Life of a Liability Insurance, No-Fault at the Use professional pre-built templates to fill in and sign documents online faster. ), Agents for insurers or workers compensation carriers. 7. Box 123613. ", " Official form 410 Mortgage Proof of Claim Attachment Page Instructions for Mortgage Proof of Claim Attachment United States Bankruptcy Court 10/20 Introduction This form can only be used in bankruptcy cases involving individual debtors. ESTATE PLAN Proof of Representation Model Language Date. Will Lawyer in Long Island Follow the step-by-step instructions below to design your representation form: Select the document you want to sign and click Upload. File: Word(.docx) 2007+ andiPad Oklahoma City, OK 73113 best estate planning lawyer Long Island Probate Lawyers If you represent the beneficiary, please read this document so that, you understand what you need for proper proof of representation. Beneficiary guardians, conservators, power of attorney, Medicare representative payees. (See page 12. 4.8 out of 5. Where no such state requirement exists, and a will is available, provide the initial page of the will, the page(s) showing the executor, and the notarized signature page(s). The representative has no independent standing, but may receive or submit information/requests on behalf of the beneficiary, including responding to requests from the MSPRC, receiving a copy of the recovery demand letter if Medicare has a recovery claim, and. Note: When you click on the sign up link, a blank e-mail should appear. Provide his/her Medicare Health Insurance Claim Number (HICN)(the number on the Medicare card). estate planning attorney in Manhattan Beneficiary designation form is used when you want to designate the people who will inherit the assets. The retainer agreement is signed by the beneficiary, The beneficiarys name and Medicare Health Insurance Claim, Number (HICN) are printed at the top of the form (this may be added after the retainer agreement is signed), and. Provide his/her name as shown on his/her Medicare card. 2022 Keifer Corporation (FZC). Estate Planning Attorney Medicare Proof of Representation Form . estate planning lawyer in Queens Once the BCRC has the appropriate documentation, it can communicate with the attorney and act upon requests made by the attorney on behalf of the beneficiary. 10,000,000+ 303. You can submit and update any documents related to your case using the Medicare Secondary Payer Recovery Portal. The friends can also be beneficiary in some cases. You should provide the same details if in another column of the secondary beneficiary if you have any. Probate Lawyer New York Proof of Representation is required for the Benefits Coordination & Recovery Center (BCRC) to communicate with and provide information to an attorney that represents a Medicare beneficiary. Will Lawyer Long Island There are many insurance policies and retirement plans that help you choose the beneficiaries who will be able to get the benefits of your assets after your demise. This form contains all those details that a person is required to provide to complete the process of designation. Retirement Planning Attorney NYC Probate Lawyers Queens The MSPRC will routinely provide a conditional payment letter (CPL) to the no-fault insurer or workers compensation entity/carrier as, soon as the conditional payment information is available if the. The MSPRC will not provide conditional payment information to a liability insurer (including self-insurance) without a proper consent to release document. Background: The three categories of crimes that can lead to felony sentences are: felony sentence and penalties Initiative statute 47 of the ", " 47 Residential real property affidavit can be amended as necessary for commercial transactions. Include the particular date and place your e-signature. ( If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process -. If a beneficiary is deceased before resolution of a Medicare, secondary payer recovery claim associated with a liability insurance (including self-insurance), no-fault insurance or workers. Relationship to the Medicare Beneficiary: __________________ In other words, you must have an appropriate chain of authorization. New York Probate Lawyer Estate Lawyer estate planning lawyer in NYC The MSPRC will provide conditional payment information to a workers compensation entity/carrier or no-fault insurer without a consent to release document. The tips below will help you fill in Medicare Proof Of Representation Form quickly and easily: Open the template in our full-fledged online editor by clicking Get form. attorney 1 refers a case to attorney 2; the beneficiary's guardian hires an attorney to pursue a liability insurance claim) or when a beneficiary's representative signs a "consent to release" document on the beneficiary's behalf, What liability insurers (including self-insurers), no-fault insurers, and workers' compensation entities 01. Save the ready-produced record to your system or print it out like a hard copy. address. The form should be started with the name, company, policy number, certificate number, and phone number etc. 15,005. ( including third part lien negotiation entities). DocHub Reviews. USLegal fulfills industry-leading security and compliance standards. estate planning in Staten Island Name: _____________________________ We will be able to look objectively at the situation like this and help determine what, if anything, is being handled improperly and what can be done better, smarter. Individuals/entities are not required to use this model language but must provide all of the information requested in the model language. Estate Lawyer Queens The MSPRC will provide conditional payment information to a, Agents must have a beneficiary specific statement (including the, beneficiarys name and HICN) on the insurer or workers compensation entitys letterhead that the agent is representing the insurer or workers compensation carrier with respect to a claim, The MSPRC will routinely provide a conditional payment letter (CPL) to the, insurer or workers compensation entity/carrier as. Pursuant to the Privacy Act, Medicare does not release information from a beneficiarys records without appropriate authorization to do so. in the Proof of Representation Model Language document. All information, files, software, and services provided on this website are for informational purposes only. ( Get the MSPRC Proof of Representation you need. Workers Compensation or No-Fault Insurance vs. will verify this status within CMS systems. 164 votes. Many people are surprised to realize just how long it can take, especially when an estate has to go through the probate court. Proof of Representation Model Language (PDF) Get email updates. Get access to thousands of forms. Retirement Planning Lawyer in Brooklyn Proof of Representation Model Language (PDF) - CMS, Proof of Representation and Consent to Release | CMS, SAIF Executive office P8-02-53, Sharjah, UAE P.O. This website is not intended to create, and does not create, an attorney-client relationship between you and FormsPal. Create a free account . This column should ask the reader to provide the information about the name, email address, the relation of the benefited with the beneficiary, social security number of each beneficiary, date of birth, the percentage of assets that each beneficiary will get. Will Attorney in NYC Estate planning in the Bronx If you are a beneficiary and have a representative, please read the information in the Rights and Responsibilities Letter and Rights and Responsibilities Brochure which explain what documentation is needed or go directly to the information provided in the Proof of Representation Model Language document. best estate planning lawyer in New York Probate Lawyer Brooklyn The retainer agreement is on attorney letterhead or accompanied by a cover note on letterhead. DO I NEED ESTATE PLANNING Where no such state requirement exists, and a will is available, provide the initial page of the will, the page(s) showing the executor, and the notarized signature page(s). 8!$;T; `I U)&X,V@tcbH0Y~0~`P8Ai%'dg (.xRu$uX9=@tmx2(if `Y@k)T(@ w 2.The representative must sign and date the document to show that he/she has agreed to represent the beneficiary. Specify the following information for the representative: name, type of representative, firm/company name (if applicable), address, telephone number. Situations where the beneficiarys representative (representative payee, conservator, guardian, power of attorney) has hired an attorney or the beneficiarys attorney has referred the case to another attorney, Beneficiarys representative has hired an attorney -- The attorney must. estate planning attorney on Long Island You can submit a Beneficiary Consent to Release (CTR) authorization request to inform the Centers for Medicare & Medicaid Services (CMS) that the Medicare beneficiary has given another individual or entity the authority to receive claims and other information related to the injury and/or illness but does not give this individual the authority to represent the Medicare beneficiary and act on . Here's how it works. Retirement Planning Attorney in NYC Beneficiary guardians, conservators, power of attorney, Medicare representative payees. USLegal has been awarded the TopTenREVIEWS Gold Award 9 years in a row as the most comprehensive and helpful online legal forms services on the market today. Power of Attorney -Submit power of attorney documents for power of attorney status if the beneficiary is incompetent you must have a durable power of attorney. Editing this form has not been simpler. Coronavirus and Estate Planning 101 Long Island Probate Lawyer information to or interact with the MSPRC, on behalf of the beneficiary, in order to resolve Medicares Recovery Claim. Get Form. Box 123613, medicare proof of rep form, medicare letter of representation, cms proof of representation form, medicare proof of representation. Box 138832 . Many forms must be completed only by a Social Security Representative. Create your signature and click Ok. Press Done. Edit your form online . This form may be used to document good faith efforts to identify a Medicare beneficiary where the injured party refuses to provide his/her necessary "Big 5" data (i.e. Open it up using the cloud-based editor and begin adjusting. Retirement Planning Lawyer Brooklyn Probate Lawyers in Queens beneficiary, in order to resolve Medicares Recovery Claim. Please call us at 1-800-772-1213 (TTY 1-800-325-0778) Monday through Friday between 8 a.m. and 5:30 p.m. or contact your local Social Security office. Liability Insurance (Including Self-Insurance), No-Fault Insurance, or Workers Compensation. !fo?^]_37'LaPeNY|Z>9\#Qri|Fwb>xq[1W~^_`N~^^-R/\>Y/loR;-sttxXo<98|J9;F/NkXX\]|\t2|^]..fw3,)!ww__->.iiz\x 6oOPx>cr&**]oYXyT~Skp|p&H8L6>-j %5"6EGvfctCiYsiWZ@xYxx\s\1oo'l\0("\|G6!v6ts >vS OiXJSi5 moAfMw!>A:S-VQ{_Ef(FmBLFa'u94m? *+-kd:XVp2[OZve-Jim3wE%E4Z9G^R"DH4 R(Ih"-!$#O#J7mis 9AF*Vi([Rj'ZK_vd 4Y=xiw%oT95^|&uWeGlYb $Ua"{"Jz"F@tMYDi;0FNYF,H0J,x[2pz[lY#@5l\LSA\1KM*qR|212U#[,Ed0:$$BhY,'@1D0k3j*(h28Q54wO*"(ug%D'L=wQ4#L,=M[la1\`9Wh#(MhWC1h]kg28 S|k?E;Y+G PoU\S mw88``"Ep16vQIAaf[F(4,G:PD4Z1Je~Wnun{dPv2N?@'W={`EN^8^Ky{>?bL|/{T#YtS}Z:IB'A*{*s)ZnIh_m1jeQ)JSSk}keo/yFvuA:KeQPjPrlg\pzZJOt%mzO|Job_{,$=wHV2~s/$SHFFuw>s7wXt It enables those people to fill the form who dont know much about the right and legal process to do so. Probate Attorney in NYC Guardian* estate planning attorney in Queens Downloads. medicare proof of representation form rating, Ifyou believe that this page should betaken down, please follow our DMCA take down process, Ensure the security ofyour data and transactions, proof of representation vs consent to release, rules and model language for proof of representation form, The National Board of Boiler and Pressure Vessel Inspectors NB-136 2017, The National Board of Boiler and Pressure Vessel Inspectors NB-136 2015. Estate Lawyer in Queens Open it up using the cloud-based editor and begin adjusting. Change the blanks with exclusive fillable areas. Access the most extensive library of templates available. Power of Attorney* Medicare Beneficiary Information and Signature/Date: For this document, the Claimant who is involved in the settlement is the Beneficiary. Beneficiary attorney refers a matter to another attorney The second. The retainer agreement is signed or countersigned and dated by the attorney. Estate Planning Lawyer During this time, this person will also be responsible for managing the estate/trust to ensure everything is kept in proper order. Pay-on-death (POD) and Transfer-on-death (TOD) designations allow the beneficiary to receive an asset upon your passing.1 A POD designation authorizes an institution to pay out the balance of a financial asset to the designated beneficiary. Long Island Probate Sometimes the power of acting as an executor seems to go to peoples heads, and they begin making decisions based on what they want more than anything else. Individuals/entities are not required to use this model language but must provide all of the information requested in the model language. Section 111 SSN Model Language Form en Espanol Probate Lawyer in Long Island Complete the empty areas; involved parties names, addresses and numbers etc. Many people are surprised to realize just how long it can take, especially when an estate has to go through the probate court. Trust Estate planning in Brooklyn of the benefited. Medicare may, provide conditional payment information to no-fault insurers or workers compensation carriers without a consent to release document. 100,000+ users . TopTenReviews wrote "there is such an extensive range of documents covering so many topics that it is unlikely you would need to look anywhere else". ( Use of the model language is not required, but any documentation submitted as a "Proof of Representation" document must include the information the model language requests. You can submit a Beneficiary Proof of Representation (POR) authorization request to inform the Centers for Medicare & Medicaid Services (CMS) that the Medicare beneficiary has given another individual or entity (such as an attorney) the authority to represent them and act on their behalf with respect to their case. Proof of Representation Model Language. Proof of Representation is required for the Benefits Coordination & Recovery Center (BCRC) to communicate with and provide information to an attorney that represents a Medicare beneficiary. estate planning attorney in the Bronx Estate Planning Type of Medicare Beneficiary Representative (Check one below and then print the requested information): Probate Lawyers in Long Island Beneficiary Representation If you have been named as a beneficiary of the estate or trust of a loved one, you may be looking forward to getting the items or money that you are due. Brooklyn Probate Lawyer to be able to link the beneficiary to you. Requesting such information specifically through an agent will delay receipt of the CPL. Will Lawyer Brooklyn Forms 10/10, Features Set 10/10, Ease of Use 10/10, Customer Service 10/10. Type. Sign up to get the latest information about your choice of CMS topics. Before you will get what you are due, the appointed executor of the estate, or a trustee, has to identify all the assets of the estate, determine their value, pay off any debts and taxes, and finally distribute the assets to the heirs. (vs. the ability to only receive certain information through a consent to release document). 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