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PARTICIPATING PROVIDER DISPUTE FORM Note: (Dispute must be filed within 2 years of the initial claim processed date. This dispute form is for participating providers and facilities only) SECTION I:
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UC Davis Health System is a renowned academic medical center that includes a top-ranked hospital and research center.
Any individual or entity that receives healthcare services from UC Davis Health System may be required to file certain documentation or forms.
To fill out UC Davis Health System forms, individuals typically need to provide personal and healthcare information as requested.
The purpose of UC Davis Health System is to provide high-quality medical care, conduct leading-edge research, and educate future healthcare professionals.
Information that may need to be reported on UC Davis Health System forms includes personal details, medical history, insurance information, and treatment received.
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