Business email address examples
[PDF File]8821 Tax Information Authorization OMB No. 1545-1165
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Tax Information Authorization ... Taxpayer name and address. Taxpayer identification number(s)Daytime telephone number . Plan number (if applicable) 2 Appointee. If you wish to name more than one appointee, attach a list to this form. Check here if a list of additional
[PDF File]Request for Leave or Approved Absence
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Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal Government furnish a social security number or tax identification number. This is an amendment to Title 31, Section 7701. Furnishing the social security number, as …
[PDF File]SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)
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SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR) PRIVACY ACT STATEMENT. Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act. To record names, signatures, and other identifiers for the purpose of validating the trustworthiness of individuals requesting access to Department of Defense (DoD) systems and information.
[PDF File]Form W-9 (Rev. October 2018)
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Address (number, street, and apt. or suite no.) See instructions. 6. City, state, and ZIP code. Requester’s name and address (optional) 7. List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding.
[PDF File]MEDICAL REQUEST FOR HOME CARE HCSP- M11Q …
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*Business Address *City *State *Zip Code . ... * Please provide this sheet to the physician filling out the Medical Request for Home Care (M-11Q). Eight Helpful Hints for Accurate Completion of the Medical Request for Home Care (M-11Q) 1. The client’s name, address …
[PDF File]REASSIGNMENT OF MEDICARE BENEFITS CMS-855R
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(“Doing Business As” Name) Practice Location Address Line 1 (Street Name and Number) Practice Location Address Line 2 (Suite, Room, Apt. #, etc.) City/Town State ZIP Code +4 PTAN for this location (if different than PTAN reported in Section 2) NPI for this location (if different than NPI reported in Section 2) CMS-855R (04/16) 2
[PDF File]Practitioner and Provider Compliant and Appeal Request
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Contact Address (Where appeal/complaint resolution should be sent) Contact Phone . Contact Fax . Contact Email Address . To help Aetna review and respond to your request, please provide the following information. (This information may be found on correspondence from Aetna.) You may use this form to appeal multiple dates of service for the same ...
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