Example: dental hygienist
PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING …

PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING …

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to the Health Care Provider on this the Signature of Health Care Provider: Printed Name: Signature of Carrier/Self Insured Employer or Utilization Review Company: Printed Name: to the Health Care Provider on this the _____ day of _____ , _____ I hereby certify that a response to the First Request and accompanying Form 1010A was

  Care, Utilization

Download PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING …


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