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FL Simply Healthcare Plans Provider Incident Report Form 2020
Get FL Simply Healthcare Plans Provider Incident Report Form 2020-2024
Hcare Plans, Inc. Clear Health Alliance Date form received: Record number: Section 1: Provider/vendor/facility information (to be completed by provider/vendor/facility) Provider/vendor/facility name: Office or group name (if applicable): Address: Office contact person: Risk manager name: Risk manager email: Phone: Provider plan ID: Phone: Phone: Fax: Section 2: Member information (to be completed by provider/vendor/facility) Line of business: Medicare Advantage Statewide Medicaid.
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