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Get Alternative Care Claim Form For Providers - Providence Health ... - Healthplans Providence

Ll not submit a claim, you can use this claim form for any alternative care reimbursement requests you may have. Your provider can help you complete this form or provide an itemized bill with the information we need to process your claim. Itemized bills must include the: Date of service Name, address, tax identification number, national provider index ("NPI") number and address of the physician or other medical provider who provided the service Diagnosis and procedure code(s) an.

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