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Get Bcbs Provider Dispute Form

Provider Dispute Resolution Request Form Submission of this form constitutes agreement not to bill the patient during the dispute process. O. Box 684249 Austin TX 78768 Provider Name National Provider Identifier NPI Number Texas Provider Identifier TPI Number Rendering Provider NPI Number Tax ID Number Street Address City State Provider Type MD Mental Health DME Rehab Other please specify ZIP code Hospital Home Health ASC Ambulance SNF CLAIM INFO.

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