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Get HCFA 855C 1998-2024

Ew HCFA Form 855 (General Enrollment Application) must be completed for the new location. If deleting a current practice location, check the appropriate box. A Post Office box or drop box is not acceptable as a practice location address. The phone number must be a number where patients and/or customers can reach the provider/supplier to ask questions or register complaints. For legal business name, supply the name that the individual or entity uses in reporting to the Internal Revenue Service (.

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