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Sbr 1 Form 2014
(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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