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 Sbr 1 Form 2014

Sbr 1 Form 2014

Use a Sbr 1 Form 2014 template to make your document workflow more streamlined.

(MM/DD/YYYY): Claim Number: Provider Information Provider Name: Contact Name: Address: City: Zip Code: Phone: Fax Number: E-mail Address: NPI Number: Claims Administrator Information Claims Administrator Name: Contact Name: Address: City: Zip Code: Phone: Fax Number: E-mail Address: Employer Name: Bill Information Provider’s or Claims Administrator’s Bill Identification Number (if any): Was Billed Service Authorized? Yes No Date Explanation of Review Received by Provider: List of disputed...
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  3. Use the Cross or Check marks in the top toolbar to select your answers in the list boxes.
  4. Utilize the Circle icon for other Yes/No questions.
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  10. Check the Help section and contact our Support team if you run into any issues while using the editor.

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