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Get Interim Payment Application Format 2011-2024

CLAIM FORM PART 1 PARTICIPANT INFORMATION PART 3 COVERAGE VERIFICATION Member Name Contact TLPP for eligibility verification prior to providing service s Subscriber ID Toll 800 252-9346 Austin 512 327-1372 Email eligibility tlpp.org Group ID Date Mailing Address Authorization No. Mailing City ST Zip Notes OBTAINING VERIFICATION IS NOT A GUARANTEE OF PAYMENT Email Address Home/Cell Phone No. PART 4 ATTORNEY INFORMATION Office Phone No. PART 2 CLIENT INFORMATION if not listed above Attorney Name A.

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