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FAX TO ENROLLMENT DEPT (617) 8970838 FAXES MUST BE RECEIVED WITHIN 24 HOURS OF THE DATE OF SERVICE IN ORDER FOR CLAIMS TO BE CONSIDERED FOR PAYMENT.PRIMARY CARE PROVIDER SELECTION Practice Name: Date:
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How to fill out 1552 pcp selection formdoc
How to fill out 1552 pcp selection formdoc
01
To fill out the 1552 pcp selection formdoc, follow these steps:
02
Begin by providing your personal information such as your full name, address, and contact details.
03
Indicate your preferred primary care physician (PCP) by entering their name, contact information, and any additional details required.
04
If you have any dependents, provide their information in the designated sections. This may include their names, dates of birth, and relationship to you.
05
Review the form to ensure all the information provided is accurate and complete.
06
Once you have verified the information, sign and date the form at the appropriate section.
07
Submit the completed form to the relevant authority or organization as specified in the instructions.
Who needs 1552 pcp selection formdoc?
01
The 1552 pcp selection formdoc is typically needed by individuals who are enrolling in a healthcare plan or making changes to their existing plan. It allows them to select a primary care physician (PCP) and provide necessary information regarding themselves and any dependents.
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What is 1552 pcp selection formdoc?
The 1552 pcp selection formdoc is a document used to select a primary care provider within a healthcare network.
Who is required to file 1552 pcp selection formdoc?
Individuals who are enrolled in a healthcare plan that requires the selection of a primary care provider are required to file the 1552 pcp selection formdoc.
How to fill out 1552 pcp selection formdoc?
The 1552 pcp selection formdoc can be filled out by providing personal information, insurance details, and selecting a primary care provider from the network's list.
What is the purpose of 1552 pcp selection formdoc?
The purpose of the 1552 pcp selection formdoc is to ensure that individuals have a designated primary care provider for their healthcare needs within a specific network.
What information must be reported on 1552 pcp selection formdoc?
The 1552 pcp selection formdoc typically requires information such as name, address, insurance policy number, and preferred primary care provider.
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