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P.O. Box 7011 Northridge, Ca 91327-7011 * (818) 368-5501 * www.signatureclaims.net Provider Sign-up Form Information DMARC Region C, A and B Date the top of Page 1 Fill in all information in the bottom

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Where to mail Palmetto refers to the specific address or location where individuals or businesses should send their documents or filings related to Palmetto services or tax forms.

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