Self-Insurance Medical Provider Billing Dispute form

Self-Insurance Medical Provider Billing Dispute form - (Forms/Publications)
Document Information
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Title Self-Insurance Medical Provider Billing Dispute form (170 KB DOC)
Description

A form for Providers to submit disputes to the department regarding payment of medical provider bills

Detail
Form number F207-207-000
Availability
Not available in print
Keywords bil, bill payment, bills, complain, complaint, dispute, interest, medical billing, medical bills, medical provider bills, non-payment, provider, underpayment
Languages English
Valid dates 12-2012
Contact information Self-Insurance
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