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Ce with item #5, Provider Responsibilities in the Protocol document, you shall maintain written permission from the providers within your domain to access their individual authorizations. This form is used to provide the NPIs associated with your domain. List all NPIs that your domain shall require access to. Please submit additional provider ids on Attachment C(a) as necessary. You may be requested to provide the list as an Excel worksheet or alternative electronic format for more than 25 NPIs.

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