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Region [Region #] Recovery Audit Contractor (RAC) Date [Request Date] [Facility Point of Contact] [Physician Practice Name] [Street Address Line 1] [Street Address Line 2] [City, State ZIP]NPI: PLAN:
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Obtain the necessary application form for the region you are applying for
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Fill out personal information accurately, including name, contact details, and address
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Provide any required documentation, such as proof of residency in that region
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Double check the form for any errors or missing information before submission
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Submit the completed form to the appropriate regional office or online portal
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