fee Schedule request form – Preferred Provider …
I am requesting:Fee Schedule (select one): c Area A c Area BIf you are unsure of your area, leave blank and a Customer Advocate will be complete on your behalf. c National Drug CodesHow would you like to receive the Fee Schedule ? c Copy of Fee Schedule on CD (Microsoft Excel spreadsheet)c Email Fee Schedule (Microsoft Excel spreadsheet)Note: Please adjust your email settings to allow email from You should receive the information in your regular email or spam folder within one week. Make sure to indicate the appropriate recipient email address Confidentiality Agreement ( Agreement ) is entered between Health Care Service Corporation, a Mutual Legal Reserve Company ( HCSC ) and , HCSC and ________________ are in the process of good faith negotiations toward the end of ______________ s agreeing to <<continue to>> participate in the HCSC <<PPO>> network; andWHEREAS, _________________________ has requested the opportunity to review HCSC s <<PPO>> Schedule of Maximum Allowances in order to assist in its final determination as whether __________________________ will agree to <<continue to>> participate in the HCSC <<PPO>> network; andWHEREAS, HCSC has advised ______
I am requesting: Fee Schedule (select one): c Area A c Area B If you are unsure of your area, leave blank and a Customer Advocate will complete on your behalf.
Download fee Schedule request form – Preferred Provider …
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