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Tallahassee FL 32309. Fax 850. 385. 1705 Copy retained by Provider MONTANA DPHHS EDI PROVIDER ENROLLMENT FORM Please return to ACS-Inc ATTN MT EDI PO Box 4936 Helena MT 59604 Or fax to 406-442-4402 Provider Billing Agent/Clearinghouse ACS EDI Gateway Inc Authorization Form Section A. Provider Information. Business Name Federal Tax ID Number Business Address City State and Zip Telephone Number Fax Number Section B. Authorization Signature required...
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