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Get OH AmeriHealth Caritas Facility Data Intake Form

Name Doing Business As (if applicable): W-9 TIN/EIN (nine characters): Primary Contact Name: UB-04/Institutional State Medicaid ID: Primary Contact Email: Address Line 1 CMS-1500/Professional Primary Contact Phone: Address Line 2 City State ZIP + 4 Digits Telephone (with Area Code) Pay to Address Recoveries Address Same as Pay To Address Organization Website: Section 2 Instructions: Please complete each section below for all locations including applicable NPI or Atypical ID inform.

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