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Get Scdhhs Provider Checklist Form

Properly account for the refund. If the form is incomplete, the provider will be contacted for the additional information. Items 1, 2 or 3, 4, 5, 6, & 7 must be completed. Attach appropriate document(s) as listed in item 8. 1. Provider Name: 2. Medicaid Legacy Provider # (Six Characters) OR 3. NPI# & Taxonomy 4. Person to Contact: 5. Telephone Number: 6. Reason for Refund: check appropriate box Other Insurance Pai.

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