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Provider Select: DTM Membership Application Participating Member Information: (Please provide all bill to and Shinto address information on page 3.) Participating Member Facility/Practice Name:Primary
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Collect all the necessary information about the participating member, such as their full name, date of birth, contact details, etc.
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Participating member information consists of details about individuals or entities involved in a particular group or organization.
The individuals or entities who are members of the group or organization are required to file participating member information.
Participating member information can be filled out by providing the required details about each member, such as name, contact information, and role in the group or organization.
The purpose of participating member information is to keep track of all members involved in a group or organization for various administrative and compliance purposes.
Information such as name, contact details, role in the organization, and any relevant identification numbers must be reported on participating member information.
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