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Medical Fee Dispute Resolution Findings and Decision General Information Requestor NameRespondent Named Tracking NumberCarriers Austin Representative Box Number 19SOUTH TEXAS RADIOLOGY GROUPM423149001INTREPID

How to fill out 73502-26-rt 72100-26 and 73552-26-rt

How to fill out 73502-26-rt 72100-26 and 73552-26-rt

1. To fill out form 73502-26-rt, follow these steps: 1. Start by providing your personal information such as name, address, and contact details. 2. Indicate the purpose of filling out the form and any relevant identification numbers if required. 3. Proceed to the specific sections and provide the requested information accurately and completely. 4. Double-check all the entered details to ensure they are error-free and logically consistent. 5. Once you have completed the form, review it again to ensure everything is in order. 6. Sign and date the form at the designated places, as required. 7. Make a copy of the completed form for your records and submit the original to the appropriate authority or recipient.
2. To fill out form 72100-26, follow these steps: 1. Begin by providing your personal details, including your full name, address, and contact information. 2. Specify the purpose of filling out the form and any additional information requested, such as identification numbers. 3. Proceed to each section and carefully fill in the required information accurately and completely. 4. Verify all the entered data to ensure there are no errors or missing details. 5. Once you have finished filling out the form, review it thoroughly to ensure its completeness and accuracy. 6. Sign and date the form at the designated areas, as required. 7. Keep a copy of the completed form for your records and submit the original to the designated recipient or authority.
3. To fill out form 73552-26-rt, follow these instructions: 1. Begin by providing your personal information, including your name, address, and contact details. 2. Specify the purpose of filling out the form and any additional information required, such as identification numbers or reference codes. 3. Proceed to each section and complete the requested information thoroughly and accurately. 4. Take care to double-check all the provided details to ensure their correctness and consistency. 5. After completing the form, carefully review it to ensure you haven't missed any required fields. 6. Sign and date the form as necessary, following the provided instructions. 7. Retain a copy of the filled-out form for your records and submit the original to the designated recipient or authority.

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