Fillable emdeon realtime provider information form and tpg

Description
PAYER NAME/ID: IOWA BCBS Emdeon Realtime Provider Information Form *This form is to ensure accuracy in updating the appropriate account* 1 Provider Organization Customer # Tax ID Practice/ Facility Name Provider Name Address Contact Name E-mail Address MID City/State Zip Code Telephone TID Fax TPG 2 Payer Payer Name/ID Group Provider ID IOWA BCBS Individual Provider ID Billing NPI 3 Confirmations...
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emdeon realtime provider information form and tpg