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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES PROVIDER NAME/ADDRESS: Millcreek Community Hospital 5515 Peach Street Erie, PA 16509 Attn: Martin Kelly PROVIDERS REPRESENTATIVE Martin Kelly
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What is PROVIDER NAME/ADDRESS: Form?

The PROVIDER NAME/ADDRESS: is a document that can be completed and signed for specific purpose. Next, it is provided to the exact addressee to provide some information of any kinds. The completion and signing is available in hard copy or via a trusted application e. g. PDFfiller. Such services help to submit any PDF or Word file without printing them out. It also allows you to customize it depending on your needs and put a legal electronic signature. Upon finishing, you send the PROVIDER NAME/ADDRESS: to the respective recipient or several ones by mail and even fax. PDFfiller offers a feature and options that make your document of MS Word extension printable. It provides various options for printing out. It doesn't matter how you'll send a document - in hard copy or by email - it will always look neat and firm. In order not to create a new editable template from scratch over and over, turn the original Word file into a template. Later, you will have a rewritable sample.

Instructions for the form PROVIDER NAME/ADDRESS:

Before starting to fill out PROVIDER NAME/ADDRESS: Word form, make sure that you prepared enough of necessary information. It is a very important part, because some typos may bring unwanted consequences starting with re-submission of the entire word form and finishing with missing deadlines and you might be charged a penalty fee. You should be careful enough filling out the digits. At a glimpse, it might seem to be very simple. Nonetheless, it's easy to make a mistake. Some people use some sort of a lifehack keeping everything in a separate document or a record book and then insert this information into sample documents. Nevertheless, put your best with all efforts and provide actual and solid info with your PROVIDER NAME/ADDRESS: word form, and doublecheck it when filling out all the fields. If it appears that some mistakes still persist, you can easily make corrections when working with PDFfiller tool without blowing deadlines.

PROVIDER NAME/ADDRESS:: frequently asked questions

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In accordance with ESIGN Act 2000, forms filled out and approved using an e-sign solution are considered as legally binding, similarly to their physical analogs. In other words, you are free to fully complete and submit PROVIDER NAME/ADDRESS: form to the institution needed using digital signature solution that fits all requirements in accordance with certain terms, like PDFfiller.

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Provider nameaddress is the name and address of the individual or organization providing a service or product.
Any individual or organization that is providing a service or product is required to file provider nameaddress.
The provider nameaddress can be filled out by including the name and address of the provider in the designated fields.
The purpose of provider nameaddress is to identify and contact the provider of a service or product.
The information that must be reported on provider nameaddress includes the name and address of the provider.
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