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Texas Department of Insurance, Division of Workers Compensation Medical Fee Dispute Resolution, MS48 7551 Metro Center Drive, Suite 100 Austin, Texas 787441609MEDICAL FEE DISPUTE RESOLUTION FINDINGS

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Start by writing the requestor's full name in the designated field on the form.

02

Next, provide the requestor's complete address including street address, city, state, and zip code.

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Make sure to legibly write each detail to ensure accuracy and smooth processing of the request.

Who needs requestors name and address?

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Any organization or entity that is collecting information or processing a request for a service may require the requestor's name and address.

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This information is crucial for identifying and communicating with the requestor, as well as ensuring the request is fulfilled correctly.

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What is requestors name and address?

The requestor's name and address are the personal details of the individual or entity submitting a request or application, typically including the full name and physical address for correspondence.

Who is required to file requestors name and address?

The individual or entity submitting a request or application is required to file the requestor's name and address.

How to fill out requestors name and address?

To fill out the requestor's name and address, clearly print the full name of the requestor and provide a complete physical address, including street, city, state, and ZIP code.

What is the purpose of requestors name and address?

The purpose of the requestor's name and address is to establish the identity of the person or entity making a request and to provide a means of contact for communication regarding the request.

What information must be reported on requestors name and address?

The information that must be reported includes the requestor's full name, physical address, and possibly other identifying details as required by specific regulations or forms.

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