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Get Cobra Administrative Services Acceptance Form As The Authorized Representative* For , (company

Ces agreement with Providence Health Plan, provided by Providence s contracted COBRA administrator, Ceridian. I request an effective date of for these services. (month / day / year) I acknowledge that the COBRA administrative services are subject to the terms and conditions stipulated in the COBRA administrative services agreement. Visit www.providence.org/php/COBRA to review the agreement. Authorize.

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