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Physical address of the location where services were provided. This is not a Post Office Box address. Pay-To Provider Information Four-lines of information: Name Address City/State/Zip Phone: 123-123-1234 Situational 3a NOTE: A PO Box is acceptable in this space. Patient Control Number Required if the pay-to provider address is different than the billing provider. Optional 3b Medical/Health Record Number Optional 4 Bill Type Required Enter your patient account number, if provided th.

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