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Get and Sign Instructions for Fax Cover Sheet When You Complete This Form Please 2018-2022

Get and Sign Instructions for Fax Cover Sheet When You Complete This Form Please 2018-2022

Use a navmc 10576 2018 template to make your document workflow more streamlined.

The Council for Affordable Quality Healthcare at https //proview. Social Security number Is your EIN/Tax ID number the same as your SSN Yes No If no enter Tax ID number below EIN/Tax ID number EIN/Tax Name as indicated on IRS document Tax exempt Medicare/PTAN number If you would like to bill with your Type 2 NPI National provider identifier representing your incorporated individual business you must also complete a New Group Enrollment form to register this entity as a group. Section 3 Primary...
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