Items A-G
Fld Name /
|
Instruction |
(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-439 |
| Author | helpdesk |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |