Items A-E
Fld Name /
|
Instruction |
A Name of Provider |
Enter the complete name of the Provider. |
(a) Name of Provider |
Enter the complete name of the Provider. |
(b) Signature of Provider |
Enter the signature of the Provider’s authorized representative. |
(c) Title of Provider |
Enter the title of the Provider’s authorized representative. |
(d) Date |
Enter the date of the signature of the Provider’s authorized representative. |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Instructions for CCC-665 |
Author | Preferred Customer |
File Modified | 0000-00-00 |
File Created | 2021-02-01 |