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2022 Claim service receipt notification

Claim service receipt notification form

Service receipts summarize the number of claims submitted to Priority Health including upfront rejections.
Billing provider group information
Practice/facility billing/pay-to information as it will appear on each claim:
9 digit number This question requires a valid number format.
10 digit number This question requires a valid number format.
8. Would you like us to fax or email you a receipt? *This question is required.
Office contact person
13. What email addresses would you like receipts to be forwarded to? *This question is required.