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Print Form Billing Dispute Resolution Request Form Provider Information Date Submitted Note All requests must pertain to a claim with dates of service that are within the timely filing guidelines. If the billing dispute pertains to a claim that is already past the timely filing limit no action will be taken* Provider Name NPI TIN Contact Person/Name Contact Number Patient/Beneficiary Information First Name Last Name HIC Number Date of Birth Claim Information Date s of Service Enter all that apply From Through DCN s Enter all that apply Note A separate form must be completed for each patient/beneficiary. Contact Resolution Information The following information is required to establish the provider s attempt to resolve the billing dispute prior to contacting Palmetto GBA for assistance. Name of Agency Contacted Method of Contact Date Agency Contacted Phone Letter Fax Other Name of Individual Contacted Is the agency out of business Yes No If yes please explain Identify the Situation Billi....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232