Get Provider Nameaddress Meredith Stempel, M - Services Dpw State Pa

This guide aims to provide clear instructions on how to complete the PROVIDER NAMEADDRESS MEREDITH STEMPEL, M - Services Dpw State Pa form online. Whether you have prior experience or are new to filling out forms, you will find step-by-step instructions to assist you in successfully completing the document.

Follow the steps to effectively fill out the form.

1. Click ‘Get Form’ button to access the document and open it for editing.
2. Begin by entering the provider name and address. For this form, input 'MEREDITH STEMPEL, M.D., LEARN ROAD, UNIT 101, P.O. BOX 597, TANNERSVILLE, PA 18372' in the appropriate fields. Ensure each part of the address is placed correctly.
3. Fill in the provider’s representative section. Here, you will enter 'MIKHAIL LEVITIN'.
4. Next, list all recipients involved by filling in the corresponding fields. If there are multiple recipients, ensure each is numbered for clarity.
5. Input the department representative's name, which in this form is 'RANDY MASON'.
6. Record the case number in the designated area. This is a crucial identifier for the form.
7. Complete the section for the date the adverse action was mailed. Enter '6/16/2003'.
8. Record the date the scheduling notice was mailed, if applicable.
9. Fill out the BHA docket numbers or issue codes where indicated. For this form, include 'W03-3201/926'.
10. Enter the dates the appeal was received and postmarked at DPW, which are '6/23/2003' and '6/27/2003', respectively.
11. Indicate the rescheduled hearing date as '8/8/2003' and specify the hearing location.
12. List the witnesses for both the provider and the department in the provided sections.
13. Record the scheduled date of the hearing, which is '8/27/2003', along with the time it is set to begin and end.
14. Complete any additional required fields, ensuring all information is accurate and organized.
15. Once all fields are completed correctly, review the document for accuracy and clarity.
16. Finally, save the changes you made. You can choose to download, print, or share the completed form as needed.

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