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Facility or Provider Name
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Doing Business As
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Tax Id Number
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Address 1
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Address 2
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City
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State
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Zip code
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Your Name (first & last)
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Phone number
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Ext
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Fax number
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Email address
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Select Type of Care
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If other, please specify
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Specialty Type (if applicable)
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Able to submit claims electronically
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Geographic Area Served
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Language, Ethnic and Cultural
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Submit your letter of interest below. Please indicate the services you offer including the geographic area you serve with any other comments/questions
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