Billing Address. This address is used for submitting all claims to HealthChoice for processing and appears in box 33 of the CMS-1500 claim form or box 2 on the UB-04. If box 2 is not used by the facility, the billing address appears in Box 1 of the UB-04. Claims will be paid exclusively to the billing address. Each address must have a corresponding phone number, email address, fax number and contact person. Insurance Certificate/Face Sheet must have name of the applicant listed as the insured. The insurance limits must be at the levels required in the contract and must indicate clearly the coverage type(s) stated in the contract. Product liability coverage in lieu of professional/medical liability is acceptable for DME only. W-9 forms must be signed and list only the Tax ID number for each location listed on the application which will be used on claim forms Claim information is available through the Medical and Dental Claims Administrator Web Site HealthChoice Connect at xxxx://xxx.xxxxxxxxxxxxxxxxxxx.xxx/. Go to Provider Login, then New Provider Registration to register for a user ID and password. Thank you for your interest in the HealthChoice Provider Network. Please complete the attached Application and submit with the required attachments listed below. Complete all sections of the application. If an area of inquiry is not applicable to the facility, please indicate. If you need additional space to provide complete answers, attach additional sheets of paper and clearly indicate the item to which each sheet applies.
Billing Address a. Review the Contract and confirm that the Obligor’s address is one within the United States, or within a United States military territory. If steps (i) through (xii) are confirmed, then Test Pass. Exh. A - 3 Asset Representations Review Agreement (BLAST 2024-2)
Billing Address. The Obligor under each Receivable had a current billing address in the United States as of the Cutoff Date.
Billing Address. All invoices must be submitted to the Webb County Business Office in electronic format and/or delivered to the following address: Webb County 0000 Xxxxxxxxxx Xxxxxx, Xxx. 203 Laredo, Texas 78040 Attn: Business Office Or email to: xxxxxxxxxx@xxxxxxxxxxxx.xxx
Billing Address. This address is used for submitting all claims to HealthChoice for processing and appears in box 33 of the CMS-1500 claim form or box 2 on the UB-04. If box 2 is not used by the facility, the billing address appears in Box 1 of the UB-04. Claims will be paid exclusively to the billing address. Each address must have a corresponding phone number, email address, fax number and contact person. Insurance Certificate/Face Sheet must have name of the applicant listed as the insured. The insurance limits must be at the levels required in the contract and must indicate clearly the coverage type(s) stated in the contract. Product liability coverage in lieu of professional/medical liability is acceptable for DME only. W-9 forms must be signed and list only the Tax ID number for each location listed on the application which will be used on claim forms Thank you for your interest in the HealthChoice Provider Network. Please complete the attached Application and submit with the required attachments listed below. Complete all sections of the application. If an area of inquiry is not applicable to the facility, please indicate. If you need additional space to provide complete answers, attach additional sheets of paper and clearly indicate the item to which each sheet applies.
Billing Address a. Publisher may have only two “xxxx to” addresses for the payment of royalties under this Agreement, one for FPUs manufactured by Authorized Replicators located in the North American Sales Territory and one for FPUs manufactured by Authorized Replicators located in the Japan Sales Territory and Asian Sales Territory. If Publisher desires to have a “xxxx-to” address in a European country, Publisher (or a Publisher Affiliate) must execute an Xbox 360 Publisher Enrollment Form with MIOL within ten (10) business days prior to establishing a billing address in a European country in the form attached to this Agreement as Exhibit 3. Publisher’s billing address(es) is as follows: North American Sales Territory: Japan and Asian Sales Territory (if different than the North American billing address): Name: Name: Address: Address: Attention: Attention:
Billing Address a. Publisher may have only two “xxxx to” addresses for the payment of royalties under this Agreement, one for the North American Manufacturing Region and one for the Asian Manufacturing Region. If Publisher desires to have a “xxxx-to” address in a European country, Publisher (or a Publisher Affiliate) must execute an MIOL Enrollment Form in the form attached to this Agreement as Exhibit 3. Publisher’s billing address(es) is as follows: North America Manufacturing Region: Asian Manufacturing Region (if different): Name: Name: Address: Address: Attention: Attention:
Billing Address. This address is used for submitting all claims to Department of Rehabilitation Services for processing and appears in box 33 of the CMS-1500 claim form or box 2 on the UB-
Billing Address. Invoices from Seller to T&D shall be sent by first class mail, courier or overnight delivery service to: Address:
Billing Address. You must notify us immediately if you change the mailing address where we send billing statements or email address to which we send notices that your billing statement is available online. . We may also update your billing address if we receive information that it has changed or is incorrect.
