Transcription of fee Schedule request form – Preferred Provider option (PPo)
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fee Schedule request form – Preferred Provider option (PPo)
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
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 be complete on your behalf.
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