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PROVIDER DISPUTE RESOLUTION REQUEST Alameda Alliance for Health Doc
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www.cms.govfilesdocumentPatientProvider Dispute Resolution Doc
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Dispute Resolution Form
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Submission of this form constitutes agreement not to bill the patient during the. Web multiple “like” claims are for the same provider and dispute but different members and dates of service. Provider dispute resolution po box 30539 salt lake city, ut 84130 note: Web to dispute a claim payment by postal mail, please submit the following request form to the.
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