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Get Ny Hp-4 2005-2024

ARBITRATION PLEASE TYPE OR PRINT THIS FORM IN BLACK OR BLUE INK ONLY. See other instructions on reverse. TYPE OF CARE: Medical Outpatient Hospital Inpatient Hospital Name and Mailing Address of Health Provider Chiropractic Physical Therapy Occupational Therapy Podiatry Psychology Osteopathic (MAXIMUM 30 CHARACTERS) Name WCB Dispute Number: Lines 1&2 Address City - Zip Code State Name and Billing Address of Health Provider Carrier or Self-Insured Employer I.D. WCB Authorizati.

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