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Fax Cover Sheet

You can use this provider fax cover sheet when submitting the following: 

  • Corrected claim requests
  • Referral information from the primary care manager
  • Duplicate claim review documentation
  • Claim check review documentation
  • Other miscellaneous requests

The appropriate fax number is listed on the cover sheet. 

  • Created: Aug 1, 2022
  • Modified: Sep 30, 2019
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