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Doctor Facility Specialty

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General Information/ Forms
File Name File Size  
Sample Explanation of Benefits Form 553 KB
H.I.P.P.A. Privacy Policy 764 KB
Student Verification Form 586 KB
Authorization for Release of Informaion - H.I.P.P.A. 669 KB
IGA Insurance Verification Form 200 KB
IGA Injury/Accident Form 89 KB
Lien & Reimbursement Agreement 98 KB
Claim Forms
File Name File Size  
Dental Claim Form 1254 KB
Vision Claim Form 820 KB
Island 65 Claim Form 572 KB
Medical Claim Form 804 KB
Claim Status Verification Form 27 KB
File Name File Size  
Provider Request Form 76 KB
Demographic Update 41 KB
Initial Out Patient Treatment Report 54 KB
Out Patient Treatment Report-Continuing 39 KB
Participating Provider Application 134 KB
Add a Provider to an Existing Contract 82 KB
W-9 (rev 11/17) 595 KB
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