Information Changes Regarding Your Practice

Please complete the entire survey and click Done when you are finished. You will not be able to save a partially completed survey.
Please note that questions 1-4 are required to submit this survey. If you answer NO to question #4 then no additional information is needed.

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* 1. Please type in the six or seven digit number located in the top right hand corner of the letter you received from us.

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* 2. Please enter the state abbreviation for your service office address.

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* 3. As a provider or representative completing this survey, I hereby attest that: (1) the foregoing responses are correct and, (2) I am authorized to provide this information on behalf of this office.
This will also serve as your signature authorizing us to make these changes to your record.

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* 4. Do you have any changes that need to be made regarding the letter you received from us?

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