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SUBMIT TO: DATE Hepatic 504 Lava ca, Suite 850, Austin, Texas 78701 FAX 877.725.7751 PROVIDER INFORMATION MEMBER INFORMATION PROVIDER NAME PROVIDER/AGENCY TAX ID # DATE OF BIRTH PROVIDER/AGENCY NPI

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Submit to refers to the act of sending or presenting something for consideration, decision, or approval.

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The purpose of submit to is to ensure that relevant information or documentation is provided to the appropriate authority in a timely manner for review, approval, or processing.

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