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's Date: (mm/dd/yyyy) ID Number: Patient: Claim Number: Provider: Date of Service: (mm/dd/yyyy) Client Letter ID: A Incident Report B Please complete this Incident Report and return it in the enclosed envelope within 45 days of receipt. If we do not receive your complete and signed Incident Report within forty-five days, all claims related to this incident will be denied until the Incident Report is received. Please be aware that if claims are denied due to tardiness in returning your comple.

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