Items A-E
Fld Name /
|
Instruction |
A Name of Provider |
Enter the complete name of the Provider. |
B Name of Provider |
Enter the complete name of the Provider. |
C Signature of Provider |
Enter the signature of the Provider’s authorized representative. |
D Title of Provider |
Enter the title of the Provider’s authorized representative. |
E Date |
Enter the date of the signature of the Provider’s authorized representative. |
| File Type | application/msword |
| File Title | Instructions for CCC-665 |
| Author | Preferred Customer |
| Last Modified By | Judy.Fry |
| File Modified | 2008-04-24 |
| File Created | 2008-04-24 |