Sending A Form or Document

 

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By submitting this form or document, I acknowledge I have written authorization to submit personal information to the Carrier/Adjudicator/Third Party Payor, and for the Carrier/Adjudicator/Third Party Payor to exchange information with other parties as required and only when the information is needed to administer and/or to confirm the accuracy of the information in the form or document.
I agree the information provided is complete and accurate, to the best of my knowledge.

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