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Electronic Payment and
Remittance Advice Application
This application constitutes an agreement between Neighborhood Health Plan of Rhode Island (Neighborhood) and its affiliated professional or
institutional
We are not affiliated with any brand or entity on this form
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Return this completed form is a form that needs to be submitted to report certain information.
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Individuals or entities who meet specific criteria outlined by the governing body are required to file this completed form.
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The purpose of this form is to collect necessary information for taxation or reporting purposes.
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