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2012 Enrollment Request Form - Providence Health Plans - Healthplans Providence
Get 2012 Enrollment Request Form - Providence Health Plans - Healthplans Providence
Tive Date of Coverage: ICEP/IEP: AEP: SEP (type): Not Eligible: Providence Medicare Advantage Plans Enrollment Request Form P.O. Box 5548 Portland, OR 97228-5548 PBP: Tran. Code: Plan #: Premiums: Please contact Providence Medicare Advantage Plans if you need infor.
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D-IRMAA FAQ
Renton, WA Providence Health & Services / Headquarters
Payer Name: Providence Health Plan|Payer ID: PHP01|Professional (CMS1500)/Institutional (UB04)[Hospitals]
Complete a claim form. Attach a copy of receipt, provider invoice that includes the provider tax ID number, CPT codes, dates of service, ICD-10 codes (diagnosis codes), billed and paid amount with your proof of payment. Make a copy for your records.
Esrd Related content
Providence Health Plan Request for Social Security...
By Mail – register your SSN or submit the annual wavier: 2012 - Providence SSN Submittal...
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